AUTOIMMUNITY OF 13F
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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.
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)
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.
On ATT (started in May)-in the months of August and sept she has complete loss of appetite,generalised weakness and weight loss(9kgs in 2yrs),attendors have lost hope and thought that she may not survive anymore in sept 2022,but later in October and nov her appetite imporved ,pedal edema decreased.
ATT stopped in October(6months)
She even went to school for 1month in December 2022
But again in Jan 2023 she started developing pedal edema,facial puffiness,pain abdomen after taking food,so she was not eating properly
She was taken to hospital in Jan 2023,doctors have adviced for further tests (as CUE showed proteinuria) and evaluation but as attendors felt that she is ok apart from that pedal edema and facial puffiness they took her home.
From yesterday night she had 4episodes of vomitings ,food as content,non bilious and shortness of breath (decreased now),so she was brought to our hospital
TREATMENT HISTORY:
History of Anti Tubercular therapy for 6 months 1 year back.
PERSONAL HISTORY:
Diet - Mixed
Appetite - Normal
Sleep - Decreased
Bowel and Bladder - Oliguria since 5 days, Bowel movements are normal
No Addictions
FAMILY HISTORY:
Mother was diagnosed with Tuberculosis in 2014.
ATT course was not taken completlely.
Symptoms got worse in 2022 and Passed way in 2022
MENSTRUAL HISTORY:
Not attained menarche
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative and well oriented to time, place and person.
After taking consent , Patient is examined in a well lit room
PALLOR - PRESENT
ICTERUS - Absent
CYANOSIS - Absent
CLUBBING-Absent
PEDAL EDEMA- PRESENT, BILATERAL , GRADE 1 PITTING TYPE
VITALS :
TEMPERATURE - AFEBRILE
BLOOD PRESSURE - 130/80 mmhg right arm supine position
No pulsus paradoxsus
PULSE RATE - 110bpm , Regular, Normal volume
RESPIRATORY RATE - 32cpm
SpO2 - 99% at room air
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM EXAMINATION:
INSPECTION:
CHESTWALL SHAPE - NORMAL
PRECORDIAL BULGE - ABSENT
PECTUS CARINATUM OR PECTUS EXCAVATUM ARE ABSENT
KYPHOSCOLIOSIS - ABSENT
NO DILATED VEINS ,SCARS, SINUSES
APICAL IMPULSE IS NOT SEEN
NO PULSATIONS ARE SEEN
JVP-NORMAL
PALPATION:
Kyphoscoliosis is absent
Apical Impulse -NOT FELT
No pulsations felt
No thrills felt
No dilated veins felt
PERCUSSION:
Right heart border is Normal
Left Heart border - INCREASED DULLNESS ON LEFT SIDE
AUSCULTATION:
S1S2 heard in all areas-Faint,soft,muffled
RESPIRATORY SYSTEM EXAMINATION
Inspection -
Supra clavicular: Present Present
Infra clavicular: Present Present
Mammary: Present Diminished
Axillary: Present Diminished
Infra axillary: Diminished Diminished
Supra scapular: Present Present
Infra scapular: Diminished Diminished
Inter scapular: Present Present
Supra clavicular: resonant resonant
Infra clavicular: resonant resonant
Mammary: resonant DULLNESS
Axillary: resonant DULLNESS
Infra axillary: DULLNESS DULLNESS
Supra scapular: resonant resonant
Infra scapular: DULLNESS DULLNESS
Inter scapular: resonant resonant
Supra clavicular: NVBS NVBS
Infra clavicular: NVBS NVBS
Mammary: NVBS Diminished
Axillary: NVBS Diminished
Infra axillary: Diminished Diminished
Supra scapular NVBS NVBS
Infra scapular: Diminished Diminished
Inter scapular: NVBS NVBS
Infra clavicular: Resonant Resonant
Mammary: Resonant Diminished
Axillary: Resonant Diminished
Infra axillary: Diminished Diminished
Supra scapular:Resonant Resonant
Infra scapular: Diminished Diminished
Inter scapular: Resonant Resonant
- MONEY BAG SHAPED HEART SHADOW
- ENLARGED CARDIAC SHADOW
- LOSS OF COSTO-PHRENIC ANGLE ON BOTH SIDES
- Liver, gall bladder , pancreas , spleen , uterus , ovaries are normal.
- Mild Ascitis
- Bilateral Pleural Effusion
- Moderate Pericardial Effusion
- Bilateral Grade 2 Renal Pelvis Dilatation changes
- Sub-mucosal edema of small bowel loops
Patient was brought to the casualty at around 9 20am
Initially drowsy but arousable after 5 min
Patient Conscious coherent
Oriented to time place person
Gcs - 15
Inconsolable cry due to headache
??Gtcs for 5 minutes at 6:30 while cooking in the kitchen
Frothing+ uprolling eye balls+no involuntary micturation+ tongue bite+
Fall+ sustained head injury at frontal area
5- 6 such episodes for 2 min while travelling to area hospital and was given Midaz
Seizure activity subsided and was brought here for further evaluation
In casualty Patient
Vitals-
Bp- 180/120mmHg
Pr - 122 cpm
Rr- 24cpm
Grbs -118mg/dl
Pupils - reactive bilaterally
Hypotonia all limbs
Reflexes
B. + +
T. + +
S. + +
K. + +
A. + +
P F. E
soft swelling over frontal area( 5×5cms)
Auscultation
Lungs Bae+
Plan :NEUROIMAGING ,ECHO,RFT
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