1801006142 - Short case

-

This is an online e log 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 problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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. 



A 32yr old male presented with complaints of swelling of face, difficulty in swallowing and change in voice since yesterday night

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 16 years back, then in 2007 after exposure to cement dust he developed sudden difficulty in breathing, inability to speak, swelling of face , lips, hands and legs. Emergency tracheostomy was done and treated conservatively and got relieved. 

He was found to be allergic to smoke inhalation of burnt plastic, garbage, any offensive smell, strawdust and cotton.  

He is also allergic to foods like Brinjal, mutton, fish and papaya. 

The symptoms aggravated even on anxiety. Swelling on face increases after any H/O trauma.

PAST ILLNESS

Patient used to develop symptoms on and off from the past 16 years. Patient was referred to Outside hospital i/v/o immunotherapy in 2011 and was treated with some unknown medication and was advised precautionary measures against allergens. 

In 2016, patient was presented with same complaints and emergency tracheostomy was done, patient since then complains of occasional swelling of face, hand and legs are seen. 

In 2021, Patient presented with complaints of swelling of face and difficulty in breathing and was treated with FFP’s, adrenaline, nebulization, hydrocort and symptoms got relieved. 

Patient had around 6-7 hospital admissions in the past 16 years.


Not a k/c/o Htn, DM, cad,thyroid disorders, epilepsy,tb


PERSONAL HISTORY

Diet: mixed 

Appetite: normal

Sleep: adequate

Bowel and bladder: regular


FAMILY HISTORY

No significant family history


TREATMENT HISTORY

Adrenaline

Nebulization

Hydrocort 

Fresh frozen plasma


GENERAL EXAMINATION

Patient is concious coherent and cooperative 

Perioral/lip edema present

Facial puffiness present 

Previous Tracheostomy scar present.

No H/O pallor, icterus, clubbing, cyanosis, lymphadenopathy.

Vitals:

Temperature 98.6F

Pulse rate 106bpm

Respiratory rate 18per min

BP 110/70 mmhg 

Spo2 98 at room air 

GRBS 110mg/dl



SYSTEMIC EXAMINATION

CVS: s1s2 heard No murmurs

RS: bilateral air entry present

P/A: soft non tender 

CNS: no focal neurological deficits

Power normal in bilateral upper and lower limbs 

Tone normal in bilateral upper and lower limbs 

No meningeal signs



PROVISIONAL DIAGNOSIS

Angioedema under evaluation


INVESTIGATIONS


CBP

Hb – 11.8

TLC – 16600

Neu – 90

Lymp – 06

PCV – 40.5

RDW – 18.2

RBC – 6.3

PLC – 5.3

BT – 2 min 30 sec

CT – 4 min 30 sec

APTT – 35 sec

PT – 18

INR – 1.33


CUE

Alb – trace

Pus cells -2- 3


RBS – 124

B.Urea – 32

S.Creat – 1.2


S.electrolytes

Na+ - 141

K+ - 3.9

Cl- - 105

Ca2+ - 11.1


LFT

TB – 0.89

DB – 0.20

AST- 21

Alt -16

ALP-124

T Protein – 7.3

Albumin -4.59

A/G -1.69


TREATMENT


Inj hydrocortisone 100mg IV stat

Nebulization with adrenaline 1amp stat

Nebulization with budecort tid 

Nebulization with duolin qid 


After Treatment:



Comments

Post a Comment

Popular posts from this blog

My Medicine Diaries...!

-
Image
1) Self reflective writing on their medical student career   I Siddarth Rangu, here to present you my adventures & experiences done in my medicine department as an Internee. As a medical intern, my daily experience  involved a mix of clinical duties and learning opportunities. I assisted in patient rounds, take histories, perform physical examinations. The workload can be intense, but it's a valuable learning experience, providing exposure to different specialties and sharpening your clinical skills. It's a challenging but rewarding period of hands-on learning. Here's one of my cases I would like to share: A 26 year old male presented with worsening breathlessness since 3 hours post binge (90ml whiskey )  His earliest recall of events dates back to when he was studying in high school ( 9th class ) during the lunch break, he felt severe breathlessness and had to sit back while playing with copious amounts of ?sputum expectoration which he describes it as yellowish in col
Read more

75yr old male with fever,pain abdomen,burning micturition.

-
Image
  This is an 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 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 inputs on the comment C/O Burning micturition since 10days,Fever since 5days, pain abdomen since 3days. Pt was apparently asymptomatic 10days back then he developed burning micturition insidious in onset gradually progressive a/w increased frequency. Then he developed fever since 5 days low grade a/w chills gradually progressive no aggravating and relieving factors.  Then he developed pain abdomen since 3 days burning type insidious in onset non radiating no aggravating and relieving factors. No H/O cough,
Read more

45 years old with shortness of breath

-
Image
 This is an 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 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 inputs on the comment . A 45 yr old female home maker by occupation presented to opd with chief complaints of shortness of breath since 15 days. HISTORY OF PRESENTING ILLNESS-  Patient was apparently asymptomatic 15 days ago . Then she developed shortness of breath which was insidious in onset gradually progressive and aggravated on stress, work and cold temperatures (Class ll NYHA ) and relieved on rest.Within to few days of onset of her shortness of breath it progressed to even at rest   ( Class lV) so s
Read more