20-03-2022

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.    

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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 50yrs old patient came to the OPD with chief complaint of shortness of breath - grade 2 since 20days 

Difficulty(pain) while swallowing solids and liquids since 3days.  Unable to open mouth since 1day. 

HISTORY OF PRESENT ILLNESS 

Patine was apparently alright 10 yrs ago and went to hospital because of headache, easy fatigability. And the patient was diagnosed with hypertension and started taking  medication.

6 years ago again patient visited the  hospital in view of weight gain and previous problem of easy fatigability and was diagnosed with Hypothyroidism. 

Patient started taking Thyronorm 50mcg.

Later was diagnosed with Rheumatoid arthritis but is not on any medication 

3 months ago diagnosed with DM and patient was not on  medication.

2 months back patient  had  cough with expectoration, pain in chest region was diagnosed as PULMONARY MILIARY TB and started ATT. After 1 month of use patient started developing redness and itching all over the body.

ATT induced Erythroderma, stopped ATT (1-2-22) for 20 days and again started using 20 days back

20days back after being discharged from a hospital admitted for ATT induced Erythroderma. Patient is having SOB (grade 2), not associated with any orthopnea/PND, pedal Edema, chest pain, or palpitations.

From 3 days patient is having difficulty in swallowing solids and liquids and from 1 day not able to open  mouth because of pain and  reddish discolouration of the tongue.

PAST HISTORY OF ILLNESS :

HTN since 10yrs on medication 

Hypothyroidism since 6yrs on thyronorm 50mcg

Rheumatoid arthritis - not on medication 

 DM since 3 months -not on medication

Pulmonary miliary TB on ATT using 3 tablets /day ( HRZE)

 

GENERAL EXAMINATION :

Patient  is conscious, coherent and irritable

Pallor + (unhealthy) 

Icterus + (sings of jaundice) 

No cyanosis/ clubbing/ lymphadenopathy 

Redness seen on her body (hands, legs, neck, back around mouth). Allergic reaction seen due to ATT.

Vitals at the time of admission 

Temperature:100F

PR: 98bpm

BP:130/80mm Hg

RR:27cpm

Spo2: 95%

GRBS:105gm%

CVS:s1s2 +

RS: BAE + , B/L crepts + (ISA, IAA)

P/A: soft, non tender , BS +

Provisional Diagnosis :

Dysphagia secondary to AKI induced 

Steven-johnson syndrome ( oral mucosistis)  

ATT secondary to Urosepsis 

with

Milliary pulmonary tuberculosis with

?nephrotic syndrome

Anemia 

16-03-2022  Normocytic, normochromic, neutrophilic leuckocytosis. 

17-03-2022  Normocytic, normochromic anemia with leuckocytosis 

19-03-2022 Normocytic, normochromic, anemia 

DM,HTN, HYPOTHYROIDISM, RHEUMATOID ARTHRITIS

INVESTIGATIONS :

15-03-2025

19-03-2022

RBS: 70mg/dl

Blood Urea: on 15-03-2022 :136mg/dl  

                on 19-03-2022 : 6.9mg/dl

Serum iron : 45ug/dl

HbA1c : 6.8%

S. Creatinine: on 15-03-2022 : 4.8mg/dl

                   on 19-03-2022 : 2.0mg/dl

CRP: POSITIVE 2.4mg/dl (range: 0-0.6)

ESR: 70 ( range:5-20)

 

ABG.               

      15-03-2022.           19-03-2022

pH.       7.34.                   7.37 

PCo2.    18.8.                   19.6

PaO2.    92.4.                   97.6

HCO3.     12.2.                   11.1

SpO2.      96.                      96.1

LFT

       15-03-2022.            19-03-2022

TB.     2.8.                        1.46     

DB.     0.74.                      0.37

AST.    14.                        18

ALT.     10.                        10

ALP.     673.                      314

TP.        7.4.                      5.6

ALB.      2.23.                     2.0

CUE

ALB ++

Sugars nil

Pus cells  :  on 15-03-2022 : plenty

                 on 19-03-2022 : 40-45

Epithelial cells  : 1-2 (19-03-2022)

COVID-19 RAT - NEGATIVE

ESR - 70

CRP - POSITIVE

15-03-2022

16-03-2022

USG Abdomen 

ECG 

Lateral view of neck

X-RAY of chest 

HRCT CHEST 

Few small volume medianal lumph nodes noted

Both lungs are studded with tiny nodular densities - Likely Milliary tuberculosis.

Small air filled cyst noted left lower lobe.

No evidence of effusion.

Non-obstructive left renal calculus.

 Reference

https://venkata-phaneendra.blogspot.com/2022/03/a-50f-with-sob-since-20-days.html?m=1

Patient Referals

DERMA

ENT 

PULMOIOLOGY 

TREATMENT

IVF NS/RL/DNS @ 75 ml/hr

Inj. NaHCO3 50meq over 10 mins + 50meq over 40 mins