50 year old with SOB

general medicine case discussion 


Makkena Naga Varsha 

MBBS 9th semester

Roll no:76

This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s 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 evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

 

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 .


Following is the view of my case..


A 50 year old lady, resident of Hyderabad, home maker by occupation, presented to GM OPD in the mid of march with 

Chief complaints
  1. shortness of breath since 20 days 
  2. difficulty in swallowing since 3 days 
  3. no able to open her mouth since a day 

History of present illness

      Timeline of events 
  •    10 years ago                
                      1. multiple joint pains with early morning stiffness, redness and tenderness
                     2. pain killers were given for joint pains
                     3. numbness and bluish discoloration of fingers to cold 

  • 8 years ago 
                           1. visited hospital for headache 
                      2. diagnosed with hypertension
                      3. started hypertension medication 

  • 6 years ago 
                          1.weight gain and easy fatigability 
                      2. diagnosed with hypothyroidism 
                      3. started thyronorm 50mg 
                      4. recurrent joint pains and diagnosed with rheumatoid arthritis 


  • 5 month ago 
                           1. visited hospital for arthralgia 
                           2. diagnosed with diabetes mellitus type 2 

  • 4 months ago
                      1. pedal edema and SOB of grade 2 
                   2. difficulty in swelling and opening mouth 
                    3. treatment : HRTC 
                    4. started ATT (1/1/22)

  • January 
                     1. excessive skin peeling over body 
                 2. ATT stopped and supportive treatment started 
                 3.  recovery after 20 days 

  • February 
              1. ATT restarted and under observation 

  • 7th march 
             1. SOB grade 2 
              2. cough with expectoration - mucoid, intermittent, non foul smelling
              3. difficulty in opening mouth and oral ulcer is present 
              4.  dysphagia not able to to take solids and liquids 


General examination :

Patient is conscious, coherent and co operative well oriented to time ,place and person.

Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

Patient is moderately built and nourished.

VITALS 

Temperature: Afebrile

Pulse rate:

Respiratory rate: 

Blood pressure: 

No cyanosis/ clubbing/ lymphadenopathy 


Personal history 

  • diet : mixed 
  • apatite : normal 
  • bowel and bladder : regular 
  • sleep : adequate 
  • addictions : no addictions

Family history

not significant 

Head to Toe examination 

  • Alopecia - Present 
  • Eyes - Proptosis seen, no conjunctival suffusion
  • EOM - Intact
  • red tongue seen
  • 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.

Systemic  Examination 
  • Respiratory examination:

    INSPECTION: Movements of chest appears to be decreased on the left side in comparison to right side.

    PALPATION: Vocal fremitus decreased in left mammary , ISA area in comparison to other areas.

    PERCUSSION: Dull note in left mammary 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 crepitation - end inspiratory - no variation with cough - heard on left ISA >>right ISA.

  • CVS examination: 

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


  • Per abdomen

    Inspection: 

    Shape – normal

    Umbilicus – Central, inverted

    Flanks – free

    Skin- no sinuses, striae are seen

    Dilated veins – absent 

    Movements of the abdominal wall with respiration is present 

     No visible gastric peristalsis and no visible pulsations. 

    Palpation: 

    No local rise of temperature  and no tenderness

    No organomegaly 

    Percussion: 

    Dullness over spleen and liver 

    Auscultation: 

    Bowel sounds heard.



  • CNS examination

    No focal neurological deficits
    Gait-     NORMAL

clinical images :   present

                                   








                                      



                                              





                                                





Diagnosis

Systemic sclerosis
Miliary TB
Dysphagia secondary to ATT induced SJS?
K/C/O HTN, DM-2, Hypothyroidism


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
P.S 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 - 70
CRP - POSITIVE

Chest X-ray

X-ray neck lateral view

ECG

USG ABDOMEN



HRCT CHEST




Few small volume medianal lumph nodes noted

Both lungs are studded with tiny nodular densities - Likely Milliary tuberculosis.

Small air filled cyst noted left lower lobe.

No evidence of effusion.

Non-obstructive left renal culculus.


Treatment
IVF NS/RL/DNS @ 75 ml/hr
Inj. NaHCO3 50meq over 10 mins + 50meq over 40 mins
NEB. Ipravent 1resp inH TID
NEB. BUDICORT 1RESP INH TID
INJ. HUMAN ATRAPID according to sliding scale
Inj. PIPTAZ 2.25 gm IV TID
T. Thyronorm 50 mg PO OD
INJ. PAN 40 MG IV OD
T. AMLONG 5 MG PO OD
MUCOPAIN JEL L/A 40 MINS BEFORE MEAL
Betadine mouth wash TID
Liquid paraffin all over body TID






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