1801006142 - Short case

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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. 

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: