1801006067 short Case
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I have been given this case to solve in an attempt to understand the topic of “ patient clinical data analysis” to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
A 13 year old Female Student came with Chief complaints of
✓Bilateral Pedal Edema and generalised body swelling since 2 months
✓Shortness of breath 5 days back
✓4 episodes of Vomitings 5 days back
HISTORY OF PRESENT ILLNESS -
The patient was apparently asymptomatic 2 years back (till she was 11 years old).
She was sent to hostel when she was 11 years old. After few days in the hostel she had bilateral neck swellings which were sudden in onset, 5-6 in number associated with intermittent fever and cough.
Then she was taken to a RMP who started her on ATT ( as her mother has Kochs).
She used ATT for 2 months.
After initiating ATT her fever increased so they stopped ATT and she was referred to Hyderabad. After Investigations, there was no AFB but the patient started having Complaints of knee pains and pain in the wrist joint. Then she was referred to another hospital where she was kept on Tab Wysolone and Tab HCQ (as the cause was suspected to be autoimmune).
Later she was taken to another local hospital with complaints of joint pains, facial puffiness, pedal edema, fever, cough. Lymph node biopsy was done which was kochs negative as informed by the attender. But she was started on empirical ATT on May 2022 and her symptoms subsided. 10-15 days before taking ATT the attendors have noticed that she was developing facial rash and Hair loss.
The patient was asymptomatic 2 months back then she developed bilateral pedal edema
5 days on she has shortness of breath on exertion and also she had 4 episodes ( 5 days back) of Vomitings with food particles as content, non bilious, non projectile, and not associated with any blood.
PAST HISTORY :
She is a known case of TB (1year back used ATT for 6 months)
N/k/c/o Hypertension, DM, epilepsy, Asthma
BIRTH HISTORY:
She is the 1st child
2nd degree consanguineous marriage
Born in 2010
LSCS - delivery
Father has no idea about immunisation status
FAMILY HISTORY :
2014 patient's mother was diagnosed with TB-expired in 2022 September (did not use ATT regularly)
PERSONAL HISTORY:
Diet - Mixed
Appetite - Decreased
Decreased urineoutput
Sleep - adequate
Addictions - None
TREATMENT HISTORY :
Used Anti Tubercular therapy for 6 months for extra pulmonary tb.
GENERAL EXAMINATION :
The patient is conscious, coherent, cooperative, and well oriented to time, place and person.
Ill built and undernourished
Pallor is present
Edema of Lower Limbs is present
No icterus, cyanosis, clubbing, lymphadenopathy
VITALS:
Temp: 98.4 F
PR: 126 bpm
BP: 130/90 mm Hg
RR: 26 cpm
SPO2: 98%
SYSTEMIC EXAMINATION :
Patient is examined in a well lit room and in a sitting position
PER ABDOMEN EXAMINATION -
Inspection -
Shape - slightly distention.
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
Palpation-
Soft, tenderness in right and left Hypochondrium, epigastrium.
Percussion
Fluid thrill and shifting dullness present
Auscultation
Bowel sounds heard
No bruit or venous hum.
RESPIRATORY SYSTEM:
Bilateral Air entry present
Vocal resonance is decreased
Dull note all over.
C V S :
S1,S2 heard
Pericardial rub is Present
No murmurs.
C N S :
No focal neurological deficits
HIGHER MENTAL FUNCTIONS- Normal
Memory intact
CRANIAL NERVES :Normal
SENSORY EXAMINATION :
Normal sensations felt in all dermatomes
MOTOR EXAMINATION :
Normal tone in upper and lower limb
Normal power in upper and lower limb
Normal gait
REFLEXES-
Normal reflexes elicited- biceps, triceps, knee and ankle reflexes elicited
CEREBELLAR FUNCTION :
Normal function
No meningeal signs were elicited
CLINICAL IMAGES -
INVESTIGATIONS-
Previous Investigations as dated on 9-10-21
ANA- Equivocal
Anti dsDNA- Positive
Fever Chart -
Hemogram
Chest X-ray
28-9-20
14-3-22
ECG-
DIAGNOSIS :
?Autoimmune disease
? Glomerulonephritis secondary to Lupus Nephritis
? Systemic Lupus Erythematosus
TREATMENT -
Fluid restriction ( 1.5 L/day)
Salt restriction (1.2 GM/day)
Inj lasix 40mg IV BD
Inj Monocef 1gm IV BD
Inj Methyl prednisolone 250mg in 100ml NS IV OD
Tab Aldactone 25mg PO OD
Tab Shelcal 500mg PO OD
Vitals monitoring
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