48 Year old female with Multi system involvement

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed.

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my cmpetancy i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  

29-03-2022

Roll no 145 - Preity Yarlagadda

CASE :

A 48 year old female, resident of Hyderabad, home maker by occupation, presented to the casualty on 14-03-22 with the chief complaints of 

• Shortness of breath since 1 month
• Difficulty in swallowing since 1 month
• Pedal edema since 1 week.
• Chest tightness since 1 week.

HOPI 

Credits : Special thanks to Dr Phaneendra (intern ) and Dr .V. Pavan kalyan(intern) for clinical images .

Past history :

• She was diagnosed with HYPERTENSION 8years back- taking regular medication
• HYPOTHYROIDISM 6years back- taking regular medication
• Rheumatoid arthritis 6 years back(no proper reports were shown presently and no medication is been taken)
• DM type-2 5 months back- not on medication
• MILIARY TB 1 month back- started on ATT (stopped)

Personal history

• Decreased appetite
• Weight loss present
• Adequate sleep
• Regular bowel and bladder movements

General examination

Patient was examined in a well lit room, after adequate exposure and taking consent.

• Patient was conscious, coherent and cooperative. She was well oriented to time, place and person.
• Pallor - Present
• Cyanosis, clubbing, icterus, lymphadenopathy - Absent
• Edema - mild, non pitting type, extending upto feet.

Vitals

Temperature : Afebrile

Pulse rate : 78 beats/min

BP : 140/90 mm Hg

RR : 18 cpm

SpO2 : 98% at room air

GRBS : 105mg/dl

Head to toe examination :

• Alopecia - Present 
• Eyes - Proptosis seen, no conjunctival suffusion
• EOM - Intact
• Bald, red tongue seen
• No ulcers
• No thyroid swelling
• Skin - Multiple hyper pigmented macules seen all over face, upper limbs, neck, thigh, abdomen and upper back.
• Dry skin present ; Thickening of skin over forearms, dorsum of hand and fingers and on and around mouth.
• Hair is absent over the macules.
• Slight peeling is still present over the arms and legs.

Credits : Special thanks to Dr Phaneendra (intern ) and Dr .V. Pavan kalyan(intern) for clinical images .

Systemic examination :

Respiratory system -

• Inspection : Movements on left side appears to be less than other side.
• Palpation : Vocal fremitus decreased in left mamary , ISA area as compared to other side.

• Percussion : Dull note in left mamary area and ISA area. 
• Auscultation : Decreased air entry on left ISA,IMA area. Right side - normal air entry. Bilateral vesicular breathing noted. Tubular breathing heard on right inter-scapular area. 
• Coarse crepitations - end inspiratory - no variation with cough - heard on left ISA >>right ISA.

Cardio vascular system :

• S1,S2 heard.
• No murmurs. No palpable heart sounds.

Per abdomen - 

• Soft, no organomegaly.
• No guarding, rigidity.
• Bowel sounds present.

Central nervous system : 

• No focal neurological deficits.
• Gait - Normal
• Rhombergs - Negative

Investigations - 

RBS: 70mg/dl

HbA1c : 6.8%

RFT

Blood Urea: 136mg/dl 

S. Creatinine: 4.8mg/dl

Na 139

K 3.0

Cl 102

Hemogram

HB 7.2

TC 15,000

MCV 80.4

PCV 21.5

MCH 27.0

MCHC 33.6

PLT 3.67

RDW 62

Peripheral smear - NORMOCYTIC, NORMOCHROMIC

Serum iron : 45ug/dl

ABG

pH 7.34

PCo2 18.8

PaO2 92.4

HCO3 12.2

SpO2 96

LFT

TB 2.8

DB 0.74

AST 14

ALT 10

ALP 673

TP 7.4

ALB 2.23

CUE

ALB ++

Sugars nil

Pus cells plenty

Epithelial cells 1-2

COVID-19 RAT - NEGATIVE

ESR - 180

CRP - POSITIVE (1.2 mg/dl)

RA FACTOR - NEGATIVE .

LDH - 326 IU/L

HRCT

• Few small volume mediastinal lymph nodes noted
• Both lungs are studded with tiny nodular densities - miliary TB or ILD? 

• Small air filled cyst noted left lower lobe.

• No evidence of effusion.

• Non-obstructive left renal calculus. 

X-RAY

USG

Raynaud's phenomenon : 

https://youtu.be/5DOd-y-rIBM

Taken from 

https://karnativaishnavi.blogspot.com/2022/03/48-year-old-women-with-multi-system.html

Provisonal diagnosis  :

Miliary TB

Systemic sclerosis?

Dysphagia secondary to ATT induced SJS?

K/C/O HTN, DM-2, Hypothyroidism, RA

Treatment :

1. Tab. Rifampicin 600mg  PO OD

2. Tab. Isoniazid 300mg PO OD

3. Tab. Ethambutol 800mg PO OD

4. Neb. Budecort BD

5. Tab. Pulmoclear PO BD

6. Tab. Amlong 5mg PO OD

7. Tab. Thyronorm 50mcg PO OD

8. Tab. Benadon 40mg PO OD

9. Protein powder 1scoop + glass milk PO BD

10. Liquid paraffin all over the body

11. Mucopain gel 

12. Inj. human actrapid

Reference - https://karnativaishnavi.blogspot.com/2022/03/48-year-old-women-with-multi-system.html

My fellow teammate : 

https://ailanibyogita.blogspot.com/2022/03/48-years-old-female-with-multisystem.html