General medicine

Thursday, 9 June 2022

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

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

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

Thursday, 31 March 2022

A case of fever ,oral ulcer,joint pain

K.sannith reddy

Roll no:55

30 year old female patient came to OPD with chief complaints of fever, rashes , joint paints.

History of present illness

Patient apparently asymptomatic 2 years ago then she developed fever, rashes , joint pains

Then she went to local hospital where they had given some antibiotics and pain killers

Symptoms subsided and recurred after some time

She continued to take this medication but symptoms were going to reccur

Lastly she went to private hospital there she diagnosed her as systemic lupus erythamatosis

It was diagnosed by renal biopsy and ANA profile

Which was

Anti -RNP/ Sm and Anti- Sm, Anti-Jo 1, Anti - ds DNA, nucleosomes and RIBOSOMAL P- PROTEIN
Biposy showed focal mild increased endocapillary cellularity pointing towards FOCAL GLOMERULONEPHRITIS
Proteinuria and increased creatinine.

She has history of hair loss

Initially 3 days of her treatment after diagnoses she developed facial puffiness blurring of vision the

She had on treatment

She was put on Tab. OMNOCORTIL 50 mg for 3 days and steroid injections and was tapered over 6 months to 2.5mg. and she is taking hydroxy chloroquine along with this

After 6 months, steroids were stopped and was started on

Tab. MFM (2 tab at 8 AM and 1 tab at 8 PM), after that she had symptoms for which they added methotrexate to it after few weeks.
IN FEBRUARY 2021, She was started on METHOTREXATE after which she noticed increase in number of oral ulcers , so she went to a private hospital 15 days later, and was started again on OMNOCORTIL 5mg
She later developed blurring of vision more in day light, for which she was diagnosed with cataract in her left eye.

After that she stopped steroid usage but she is on MFM and HCQS till this day

After that she lost vision on both eyes and under went cataract surgery on Feb 12

From last 6 months she is having mouth ulcers on and off

But from last 7 days she is having increased symptoms of ulcers joint pains fever such that

She is not able swallow foods with this history she came to this hospital .

Past history :

Patient is a known case of HYPOTHYROIDISM since and is on Thyronorm 50mcg .

Not a known case of DM, HTN, EPILEPSY, TB, BRONCHIAL ASTHMA

PERSONAL HISTORY:

DIET- mixed

Appetite: Normal

Bowel and bladder movements are normal

Sleep: Adequate

No known addictions and allergies.

Menstrual History:

She bleeds for 3 days in a 30 day cycle

She uses 3 pads per day.

Recently, she complains of spotting 5 days before her first day of menses ( oligomenorrhea)

Marital history:

In 2014 Dec, when she was 24 years she was a married.

Antenatal history:

P3 L2 A1

In 2015, her first pregnancy reached full term and NVD was done.

She developed high grade fever in her 6th month, and was diagnosed with malaria.

She developed severe back and loin pain in her 8th month, and USG was done which showed swollen kidneys for which she was prescribed antibiotics and sent home.

In 2018, her second pregnancy, she suffered an abortion in the 4th month. On investigation, she was found to be suffering from Hypothyroidism and was started on medication.

In 2019, her third pregnancy, reached full term and NVD was done.

Family History:

Insignificant

General examination:

Patient is conscious, coherent and cooperative.

Vitals on admission:

Temp: 102°F

BP: 120/80

PR: 110 bpm

CVS:

On palpation,

-Apex beat felt at 5th intercostal space along midclavicular line