FINAL EXAM- SHORT CASE

 47 Year old female patient with fever and joint pains ( short case)

June 09, 2022

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 

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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.        

H no : 1701006076

A 47 year old female tailor by occupation resident of nalgonda came to the OPD on 2_06_2022 with the chief complaints of 

Fever since 3 months

Facial rash from 15 days

TIME LINE OF EVENTS : 

                

             DIMINISION OF VISION since 20months

            COVID vaccination in aug 2021 

             Post vaccination joint pains.  

            Consulted orthopedic doctor in Nov 2021

            Symptoms relieved 

            Fever ( March 2022)

            Joint pain 

            Rash

History of presenting illness: 

Patient apparently asymptomatic 10 years back later she developed joint pains (in ankle and knee) it was associated with morning stiffness and limitation of joint movement . This get usually relieved after some activity .

For joint pains she went to local hospital where she tested RA positive.symptoms relieved on medication (diclofenac)

Last year she took COVID vaccination.

Later she developed joint pains

After which she consulted orthopaedician and symptoms relieved by taking medication

3months back she had joint pains and fever which was Insidious in onset Intermittent on and off not associated with chills and rigor. 

She went to the private hospital but the fever was recurrent associated with abdominal pain came here on 2/6/22

Patient also had facial rash over the face which increased on exposure to sun. It was a diffuse erythematous lesion and hyperpigmented papules were noted over the bilateral cheek sparing nasolabial folds and it developed from last 15 days

Past history:

Patient had an history of gradual painless loss of vision since 2011and was certified as blind 2 years back

Not a known case of diabetes asthma Epilepsy thyroid tuberculosis and coronary artery disease. 

Family history:

No similar complaints in the family

Personal history

DIET- mixed

Appetite: Normal

Bowel and bladder movements are regular

Sleep: Adequate

No known addictions and allergies.

General examination

Pateint is consious ,coherent ,co operative well oriented to time place and person,moderately built and moderately nourished and is examined with informed consent.

Pallor: present 

No icterus, cyanosis, clubbing,lymphadenopathy, edema.

VITALS

PULSE :86BPM

BP:120/80mm hg

RR:16cpm

SPO2:98%at room air

LOCAL EXAMINATION :

Erythematous rashes seen bilaterally around cheeks and nd it is insidious onset and gradually subsided

 A swelling seen on lateral aspect of left lower limb just above the ankle joint associated with itching ,redness, throbbing type of pain& non radiating .

Later pigmentation seen .

SYSTEMIC EXAMINATION

CVS examination: 

Inspection:SHAPE OF THE CHEST IS NORMAL

no visible neck veins

No rise in JVP

No visible pulsation scars.

Palpation:

ALL inspectory findings are confirmed 

Cardiac impulse felt at 5th intercostal space 1cm medial to the mid clavicular line.

Percussion shows normal heart borders

Auscultation: s1 s2 heard no murmurs

CNS examination:

Higher mental function normal 

Cranial nerve examination normal 

Normal motar and sensory system on examination

Respiratory examination:

 Inspection

Shape of chest is elliptical, 

B/L symmetrical chest,

Trachea in central position,

Expansion of chest- normal on both sides

Palpation

All inspectory findings are confirmed,

No tenderness, No local rise of temperature,

Percussion

normal resonant note present bilaterally 

auscultation: normal vesicular breath sounds heard 

GIT 

inspection- normal scaphoid abdomen with no pulsations and scars

palpation - inspectory findings are confirmed

no organomegaly, non tender and soft 

percussion- normal resonant note present, liver border normal

auscultation-normal abdominal sounds heard, no bruit present 

INVESTIGATIONS:

CBP

Hemoglobin- 6 gm/dl 

PCV- 21 % 

TLC- 8200/ cumm 

RBC- 2.5 million/cumm 

Platelets- 1.32 lakhs/ml 

RA Factor- 34.4 IU/L 

Blood urea- 24 mg/dl (N)

Serum creatinine- 1.3 mg/dl (N)

Serum sodium- 136 mEq/L (N)

Serum potassium- 3.7 mmol/l (N)

Serum chloride- 104 mEq/L (N)

Rheumatoid factor positive 

Anti Ro antibodies - positive

LFT

Total bilirubin- 0.61 mg/dl (N)

Direct bilirubin- 0.16 mg/dl (N)

SGPT- 48IU/L 

SGOT- 55IU/L 

ALP- 194 IU/L 

Albumin- 4 g/dl (N)

XRAY

Ophthalmology report :

Bilateral optic atrophy 

PROVISIONAL DIAGNOSIS:

SECONDARY SJOGRENS SYNDROME 

LEFT LOWER LIMB CELLULITIS WITH BILATERAL OPTIC ATROPHY

Treatment given :

1.INJ PIPTAZ 4.5 gm IV/ TID.

2.INJ METROGEL100 ML IV/TID

3.INJ NEOMOL1GM/IV/SOS

4.TAB CHYMORAL FORATE PO/TID

5.TAB PAN 40 MG PO/ OD.

6.TAB TECZINE10 MG PO/OD

7.TAB OROFERPO/OD.

8.TAB HIFENAC-P PO/OD

9.HYDROCOTISONE cream 1%on face for 1week. 

Final exam - LONG CASE

A 51 year old male patient with fever ,cough and shortness of breath.

   HALL TICKET NO: 1701006076                   

       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 competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.   

        51 year old male patient who is resident of chityal ,and works in a transportation company came to the hospital with complaints of 

1- Fever since 10 days

2- Cough since 10 days 

3-shortness of breath since 6 days 

History of presenting illness : 

Patient was apparently asymptomatic 10 days back, then he developed....

Fever since 10 days which was high grade , with chills and rigors , Intermittent, relieved with medication.

Associated with cough and shortness of breath.

Cough since 10 days which is productive ,mucoid in consistency,whitish ,scanty amount ,more during night times and on supine position ,non foulsmelling ,non bloodstained .

Right sided chest pain - diffuse , intermittent ,dragging type , aggravated on cough ,non radiating ,not associated with sweating , palpitations.No chest tightening.

Shortness of breath since 6 days , insidious onset , gradually progresive ,of grade 3 - (MMRCscale) ,not associated with wheeze ,no orthopnea ,no Paroxysmal nocturnal dyspnea, no pedal edema .

 History of pain abdomen 

No history of , vomiting ,loose stools .

No history of burning micturition.

Past history : 

Patient gives history jaundice 15 days back that resolved in a week .

No history of Diabetes , Hypertension , Tuberculosis ,Bronchial asthma ,COPD , coronary artery disease , Cerebrovascular accident ,thyroid disease.

Family history : 

No history of Tuberculosis or similar illness in the family 

Personal history : 

Patient is a chronic smoker - smokes 5 cigarettes per day from past 25 years .

He is a Chronic alcoholic - cosumes 300 ml whisky per day ,but stopped since 3 months.

No bowel and bladder disturbances

Summary : 

51 year old male patient with fever ,cough , shortness of breath possible differentials 

1- Pneumonia 

2- Pleural effusion 

GENERAL EXAMINATION : 

He is conscious, coherent, cooperative

Patient is moderately built and nourished.

No signs of pallor ,cyanosis ,icterus ,koilonychia, lymphadenopathy ,edema .

Vitals : 

Patient is afebrile .

Pulse - 86 beats / min ,normal voulme ,regular rhythm,normal character , radioradial delay.

BP - 110/70 mmhg ,measured in supine position in both arms .

Respiratory rate -22 breaths / min

SYSTEMIC EXAMINATION : 

Patient examined in sitting position

RESPIRATORY SYSTEM:

Upper respiratory tract -

oral cavity- Nicotine staining seen on teeth and gums , nose .

oropharynx appears normal. 

CHEST examination: 

Inspection:

Chest appears Bilaterally symmetrical & elliptical in shape

Respiratory movements : abdomino-thoracic type.

Respiratory movements appear to be decreased on right side.

Trachea is central in position 

Nipples are in 4th Intercoastal space

Apex impulse visible in 5th intercostal space

No dilated veins, scars, sinuses, visible pulsations. 

No rib crowding ,no accessory muscle usage.

Palpation:-

All inspiratory findings are confirmed by palpation.

No tenderness.

No local rise of temperature

Trachea central in position

Apical impulse in left 5th ICS, 1cm medial to mid clavicular line.

Decreased expansion of chest on right side .

Tactile vocal Phremitus - reduced on right side in mammary, infraaxillary,interscapular and infrascapular region.

Normal on left side 

Anteroposterior diameter : 32cm

Transverse diameter : 26cm 

Chest circumference : 95cm expiratory

                                        98 cm inspiratory

PERCUSSION : 

Stony dullness is observed

 Region                    Right             left 

Supraclavicular    Resonant      Resonant 

Infraclavicular     Resonant.      Resonant. 

Mammary.             Dull.               Resonant

Axillary                  Dull.               Resonant 

Infra-axillary        Dull                Resonant

Suprascapular      Resonant       Resonant 

Interscapular        Dull                Resonant 

Infrascapular        Dull                Resonant

Shifting dullness is seen .

AUSCULTATION: 

                                    Right.                Left.

Supraclavicular.      NVBS.                NVBS

Infraclavicular.       NVBS.                 NVBS

Mammary.               Decreased.         NVBS

Axillary.                    NVBS.                 NVBS

Infra-axillary.         Decreased         NVBS

Suprascapula         NVBS.                  NVBS

Interscapular.        Decreased           NVBS

Infrascapular.        Decreased           NVBS

NVBS- normal vesicular breath sounds 

Other systems examination : 

Gastrointestinal system : 

 Inspection - 

Abdomen is distended.

Umbilicus is central in position and slightly retracted and inverted.

All quadrants of abdomen are equally moving with respiration except Right upper quadrant .

No visibe sinuses ,scars , visible pulsations or visible peristalsis

Palpation 

All inspectory findings are confirmed.

No local rise of temperature.

 tenderness on palpation in right hypochondrium.

Liver - is palpable 4 cm below the costal margin and moving with respiration.

Liver span increased(18cm)- normal is 13cm

Spleen : not palpable.

Kidneys - bimanually palpable

Percussion:

Percussion is normal.

Auscultation- bowel sounds heard .

No bruits and venous hum.

 CVS EXAMINATION: 

S1,S2 heard ,no murmers 

CNS EXAMINATION: 

Higher mental function normal 

Cranial nerve examination normal 

Normal motor and sensory system on examination

INVESTIGATIONS :

XRAY:

ELLIS curve (s shaped curve/Damoiseaus curve): curved shadow at the lung base, blunting the costophrenic angle and ascending towards the axilla. 

PLEURAL FLUID ANALYSIS : 

Colour - straw coloured 

Total count -2250 cells

DLC - 60% Lymphocyte, 40% Neutrophils 

No malignant cells.

Pleural fluid sugar = 128 mg/dl

Pleural fluid protein / serum protein= 5.1/7 = 0.7 

Pleural fluid LDH / serum LDH = 0.6

INTERPRETATION: 

Exudative pleural effusion.

Serology - negative 

Serum creatinine - 0.8 mg/dl 

CUE - normal

 CT SCAN- abdomen & pelvis

FINAL DIAGNOSIS :

1. Right sided pleural effusion 

2. Right lobe liver abscess 

TREATMENT :

Inj. PIPTAZ 2.5gm iv QID

Tab. AZITHROMYCIN 500 OD

Inj. METROGYL 100ml TID

Tab. DOLO 650mg

Inj. NEOMOL 1gm IV

O2 inhalation

IV fluids: normal saline

Inj optineuron

Temperature chart 4 hrly

Bp, Sp02 chart 4hrly

Inj.AMIKACIN iv BD