Final practical exam long case medicine discussion

 1701006082;( long case)

I’ve 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

K.shirisha

Hall ticket number; 1701006082

9th semester.      

                                                                                              case discussion;

A 47 year old female patient Tailor by occupation .resident of Nalgonda came to the opd on 31/5/22.

Chief complaints;

Shortness of breath since 15 days

Fever since 1 month

Generalized weakness since 2 months

Multiple joint pains since 2-3 months

History of present illness;

The patient was apparently asymptomatic 15years ago then she developed a multiple joint pains .which was insidious in onset and gradually progressive . Pain was fleeting type associated with morning stiffness .and not associated with swelling.

Pain was more over the wrist and knee.

Aggrevated on doing work and relieved by medication.( Diclofenac tablet)

* On August she had received a covid vaccine .after that she developed multiple joint pains. due to which she consulted a local doctor( orthopaedic).and recieved a medication.( Diclofenac injections for 1 week) then pain was relieved.

* On 22/11/21

She again consulted orthopaedic for polyarthritis .  and some tests were done

RA factor was negative.and she was recieving medications (nsaids).

She was consulting a orthopaedic monthly twice till 14/4/22.

On 14/4/22;

She had fever which was high grade .on and off . Associated with joint pains .she consulted a local doctor.and prescribed some medications which was relieved.

On5/4/22;

 patient was having an episode of loss of consciousness with cold peripheries with sweating [grbs 7mg/dl] after taking Tab Glimi M2 prescribed by a local practitioner for high sugars?250mg/dl.

On 30/5/22:

She had fever which was on and off . associated with shortness of breath on exertion. And consulted a local doctor there tests were done. 

Widal test ; positive

RA factor ; positive

C/O erythematous rash over face with itching . Since 1 week. Aggrevated on drug usage.

C/O swelling of left foot with redness and local rise of temperature

C/O generalized body pains

C/O loss of appetite,

C/O hair loss 

C/O weight loss (72- 46 kg)

C/O caries tooth more on lower jaw

C/O dry lips, blepharitis, mouthulcers.

C/O decreased sweating.

Past history;

Patient had a history of diminution of vision at age of 15 years started

 using spectacles but there was gradual, progressive, painless loss of vision was certified as blind 2 years back .

Family history;

Her younger sister had similar complaints of joint pains .she is recieving medications since 10 years

Menstrual history; 

Age of menarche; 14 years of age 

28 days cycle , regular

Menopause : 1 year ago

Obstetric history;

G1 L1

Male boy,15 years old, immunized, exclusive breastfeeding for 6 months ,mole stones achieved

Personal history;

Appetite ; decreased

Diet ; mixed

Bowel and bladder; regular

Sleep; adequate

No addictions

General examination;

The patient is conscious, coherent,cooperative, moderately built and nourished.

Pallor ; present

No icterus , cyanosis,clubbing , lymphadenopathy,edema.

Vitals;

Temperature; afebrile at the time of presentation

Blood pressure; 110/70 mmHg

Heart rate; 72bpm, regular, normal volume

Respiratory rate; 14 cpm

LOCAL EXAMINATION:

Swelling was noted at left lower limb on lateral aspect of ankle which is red in color, tenderness, local rise of temperature,all pulses like anterior tibial,posterior tibial,dorsalis pedis pulses were felt

Erythematous rash, hyperpigmented present on face ,sparing nasolabial folds.

Parotid gland enlargement

Systemic examination;

Respiratory system;

Inspection of upper respiratory tract

Oral cavity ; 

Dental caries;  partial loss of tooth ( due to decreased saliva production)

Dry ,fissured tongue,  peeled cracked lips due to decreased saliva production

Nose; no DNS,polyp

Pharynx ; normal

Lower respiratory tract

Position of trachea; midline

Position of Apex beat; left5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

Palpation ;

Position of trachea,apical pulse is confirmed

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

Percussion;

Resonant note heared,no obliteration on traubes space

Auscultation ; 

BAE-PRESENT

Normal vesicular breath sounds,no wheeze or no adventitious sounds

GIT;

Per abdomen;

Shape; scaphoid

Umbilicus; central

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

Palpation; liver palpable 4cm below the costal margin with liver span of 15.5 cm,soft non tender With regular margin and smooth surface with no intercostal tenderness

* Splenomegaly, no tenderness,or local rise of temperature

Percussion ;

Liver; dullnote heared

No fluid thrills,shifting dullness

Auscultation;

Bowel sounds are heared

Cardiovascular system;

Inspection;

Position of trachea ;midline

No visible pulsations,no raised jvp

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation; S1,S2 heart sounds are heared , no added murmurs,

Central nervous system;

Higher mental functions : 

Level of consciousness: normal

Speech : normal

Mental state;

Memory;  normal,meningeal signs; negative

Cranial nerves;

1 ) olfactory nerve ; percieves smell

2) optic nerve :  

Visual acuity ; Right eye. ; Counting finger 1/2          Left eye; counting finger 1/2

3) occlomotor nerve ; normal

4) trochlear nerve ;  normal

5) trigeminal nerve ; normal

6) abducens nerve ; normal

7) facial nerve; normal

8) vestibuli cochlear nerve; normal

9) glossopharyngeal nerve; normal

10)vagus

 nerve ; normal

11) spinal accessory nerve ; normal

12) hypoglossal nerve ; normal

Gait: normal

Motor system ;

Power  U/L         L/L

   Right   5/5        5/5

    Left      5/5        5/5

Tone        U/L                    L/L

Right       normal.        Normal

Left          Normal             Normal 

Reflexes   Biceps triceps supinator knee ankle 

Right             2+             2+            2+      2+.   2+

Left                  2+             2+.          2+.   2+.   2+

Plantar reflex: flexor

Sensory system : normal

Cerebral signs;

Finger nose in coordination; yes

Knee heel in coordination; yes

Ophthalmology ;( referral notes)

SURGERY

Dermatology ;

Investigations;

 

Previous; complete blood picture

C- peptide serum

ECG; (0n30/5/22)

Interpretation; sinus tachycardia

X ray chest;( 22/11/22)

30/5/22

Impression; B/L minimal pleural effusion with basal lung consolidation

Ultrasound ;

Hepatomegaly with grade- 2 fatty liver

B/L minimal pleural effusion with basal lung consolidation

Widal test; positive

ESR; elevated

C-reactive protein ; elevated

TSH; normal

Hemogram:

Hemoglobin:: 6gms%

RBC: 2.5million/cumm

Platelet count: 1.32lakh/cumm

PCV: 21

Peripheral smear:

Normocytic hypochromic

Relative monocytosis

Mild decrease in platelets

X ray hand (31/5/22)

Chest x ray;

31/5/22

Complete blood picture;

HB: 6.9

Total leucocyte count: 9700

Platelet count: 1.57

MCV: 85.1

MCH: 27.1

MCHC; 31.8

PCV; 21.7

ESR; 90

RBS: 136

CRP: negative

Renal function tests:

Urea: 20

Creatinine: 1.1

Total bilirubin: 0.45

Direct bilirubin: 0.17

AST: 60

ALT: 17

ALP: 138

Total protein: 6.3

Albumin: 2.18

A/G; 0.53

Serology: 

HCV,HBV,HIV; negative

Sodium: 136

Potassium: 3.3

Chloride-: 98

Serum iron: 

Serum ferritin: 618.7

Complete urine examination;

Albumin: +

Sugar: nil

Pus cells: nil

RA factor: negative

Reticulocyte count: 1.7

B/G/T: AB+

24 hour urine creatinine: 0.6

24 hour urinary protein: 137

24 hour urinary volume: 1700

2/6/22

Hemogram

Hemoglobin; 7.7g/dl

Total leucocyte count: 5300cells/cumm

Neutrophil:73%

Lymphocytes-: 20%

Eosinophils: 1%

Monocytes-: 06%

Basophils: 0%

PCV; 24.6

MCV: 86fl

MCH: 26.9pg

MCHC: 31.3%

RDW-CV: 19.9

RDW-SD: 62.5

RBC count,: 2.86 million/cumm

Platelet count: 1.83 lakh/cumm

Smear;

Anisocytosis

 

ECG;

ANA; ( antinuclear antibodies)

 Ana 17 b test positive;

As antibodies are detected against ss-A /Ro 60 antigen

SS-A/ Ro 52 antigen

Nucleosomes antigen

SS-B/La antigen

 

Temperature chart;

Diagnosis;

? Secondary sjogren syndrome

Anaemia secondary to chronic inflammatory disease

with LT LL cellulitis 

B/L Optic atrophy

Treatment;

On 31/5/22;

1) inj piptaz 4.5gm iv tid

2) inj metrogyl 100ml iv tid

3) tab dolo650 mg po

4) inj neomol 1 gm iv

5) inj optineuron 1 ampoule in 100ml ns od

6) tab hifenac po bd

7) tab pan 40mg po od

8)inj nervigen 1 ampoule in 100ml ns

Cellulitis treatment:

1) tab chymoral forte tid

2) tab hifenac: bd

3) tab pan: 40mgod

4) mgso4 dressing

5) limb elevation

On 6/6/22;

1) tab deflozocart 6mg po/ BD

2) tab cefixime 200mg po/bd

3) tab orofer xt po /of

( 15 minutes before food)

4) tab rantac 150mg po/od

5) tab teczine 10mg po/ of/ha

6) hydrocortisone cream 1% /LA/ for face for 1 week