This is an online elog book to discuss our patient de identified health data shared after taking his/ her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evident based input
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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
Presenting compalaints
13year old female
Came with chief complaints of Shortness of breath since yesterday (decreased now)
4 episodes of vomitings since yesterday 10pm
Birth history
1st child
2nd degree consanguineous marriage
Born in 2010
LSCS
Father has no idea about immunisation status
Mother-has 2 children
The current pt is the elder one(birth in 2010)
2nd child born in 2013
In 2014 mother diagnosed with kochs-expired in 2022 sept(did not use ATT regularly)
History of presenting illness
Patient was apparently asymptotic till the age of 11years
She was sent to hostel for studies
After few days of hostel stay she noticed that she has bilateral neck swellings
So she was taken to RMP with complaints of neck swellings,fever and cough on and off
RMP has initiated her on ATT as her mother has also has kochs
They used ATT for 2months started in 2021 june
After initiating ATT fever increased so they stopped ATT and was referred to Hyd by the RMP
Patient was taken to NF hospital where she was evaluated for kochs but none of the investigations showed AFB,at that time she also had complaints of knee pains and wrist joint pains
In view of joint pains she was referred to N hospital
In N hospital they suspected it to be autoimmune and started her on Tab Wysolone and Tab HCQ ,which she used for 15 days and stopped and later did not go there for follow up
(ANA ELISA-equivocal,ANA IFA-negative,Anti Ds DNA ELISA-Positive,Anti Ds DNA IFA negative)
She was taken to another local hospital with c/o joint pains,facial puffiness,pedal edema,fever ,cough
Lymph node biopsy was done in May 2022 ?reactive(no report available but attendor was informed that it was negative for kochs)
So Mycobacterial gene expert test was done on blood sample which was also negative
But she was initiated on ATT empirically on may/2022.
10-15days before starting ATT attendors have noticed that she is developing facial rash and Hair loss,due to hair loss scalp rash also became evident.
History of past illness:
K/C/o extra pulmonary tb (1year back used att for 6 months)
N/k/c/o hypertension, DM, epilepsy, cad, Cva
Treatment history:
Used att for 6 months for extra pulmonary tb.
Personal history:
Single
Occupation:student
Decreased appetite and micturition
General examination:
Pallor +
Edema +
No icterus cyanosis clubbing lymphadenopathy
Systemic examination:
CVS: s1 s2 heard, no murmurs
RS: BAE + , NVBS
P/a : free fluid present
Tenderness + at right and left hypochondria and epigastrium
Cns: pt is C/C/C
No FND
HMF +
Right. Left
Biceps. ++ ++
Triceps. 2+ 2+
Supinator. + +
Knee 2+ 2+
Ankle. + +
Clinical images
Investigations
Differential Diagnosis
Glomerulonephritis secondary to ? Lupus ? Autoimmune etiology with polyserositis secondary to autoimmune / ? Tuberculosis
Treatment
1. FLUID RESTRICTION LESS THAN 1.5L/DAY
2. SALT RESTRICTION LESS THAN 1.2GM/DAY
3. INJ. LASIX 40 MG IV/BD
4. INJ. MONOCEF 1GM IV/BD(D2)
5. INJ. METHYLPREDNISOLONE 250 MG IN 100ML NS IV/OD
6. TAB. ALDACTONE 25MG PO/OD
7. TAB. SHELCAL 500 MG PO/OD
8. VITALS MONITORING
