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 and treatment plan.
I have prepared this blog under the guidance of
Dr. Sai Charan Kulkarni, Dr. Deepika
https://drkranthimenmula.blogspot.com/2022/08/47-year-female-with-abdominal-distention.html?m=1
A 47 year old female brought to casualty with chief complaints of
-progressive swelling of both legs , arms since 1 week and
-distension of abdomen since 1 week .
History
Patient was apparently asymptomatic 20years back. She used to do farming at cotton and paddy fields.
Her daily routine starts at morning 6am . After regular needs she goes to paddy and cotton fields. She observed her fingers tips turned white and cold with tingling sensation when she put her finger in water while planting. She works till 4-6pm and then returns home , does household chores and used to have her dinner and sleeps by. 9-10 pm.
8years back she had generalized itching following which she consulted nearest medical center and diagnosed with diabetes and was started on oral hypoglycemic drugs. She used to check her RBS once in 2-3 months
3 years back she had high grade fever associated with chills. She went to hospital and was told that her sugars were poorly controlled and was started on INJ.INSULIN (intermediate acting) with 20--x--15 U. / Day. Then she used insulin for 2 years and then stopped due to financial issues and continued on OHAs for 3 months. Then she noticed bilateral lower limb swelling initially below ankle and then gradually progressed to upper limb with mild distension of abdomen . She went to hospital and then refused to get admitted due to personal reasons and took treatment on op basis. The was on diuretics for 20 days . Then she was able to manage her daily self needs .
1 year back she was admitted to Kims narketpally for similar complaints and was evaluated for anasarca and possible differentials of ? TB Ascites , nephrotic syndrome, heart failure was considered.
Clinically diagnosed TB 2 and half months back and was started on ATT.
After 10 days she developed generalized itching with rashes(ATT induced ) and was stopped and was resumed on 3rd September 2022.
The patient developed generalized body swelling associated with abdominal distension and SOB grade 2 since 1 week. Dry cough since 1 week.
PAST HISTORY: K/C/O DM TYPE 2 SINCE 8 years
H/o of TB since 2 months .
N/k/c/o HTN, epilepsy, asthma
FAMILY HISTORY
Personal history:
Diet - mixed
Appetite -normal
Sleep-adequate
Bowel and Bladder -normal
General examination
Patient is concious coherent and cooperative well oriented to time place and person
Pallor - present, no Icterus, clubbing , cyanosis, generalized swelling, no lymphadenopathy.
Vitals on presentation
BP- 150/80mmHg
PR-110bpm
RR-15cpm
SPO2-96%
GRBS-364 mg/dl
CVS- S1 S2+
RS-BAE +
P/A-non tender
PROVISIONAL DIAGNOSIS:
PORTAL HYPERTENSION 2° ? MCTD ? SJOGRENS ? systematic sclerosis with nephrotic syndrome 2° to diabetes? Lupus
INVESTIGATIONS:
Hemogram, cue, LFT, RFT
ascitic fluid : -
LDH -66
PROTEIN - 0.8
SUGAR- 367
5/10/22
6/10/22
TREATMENT:
IV fluids NS @UO+30 ml/hr
Tab. LASIX 60 mg PO/TID
Tab . METOLAZONE 10 mg PO/BD
Tab. DOLO 650 mg PO SOS
Continue ATT:
TAB. ISONIAZID 300 mg PO/OD
TAB. RIFAMPICIN 450 mg PO/OD
TAB.PYRAZINAMIDE
SYP. GRILLINCTUS 10 ml PO/TID
PROTEIN - POWDER in 100ml of milk twice daily.
6/10/22
S:
Sob improved.
O:
Pt is concious coherent and cooperative
PR-108bpm
RR-22cpm
BP- 140/80mmHg
Spo2-98% in RA
Temp- 97.7
A:? NEPHROTIC SYNDROME
P:
IVF NS RL @ UO + 30 ML/HR
Inj. LASIX 120MG/HR IV/BD
CONTINUE ATT
TAB .ISONIAZID 300MG PO/OD
TAB.RIFAMPICIN 450MG PO/OD
TAB.PYRAZINAMIDE 250MG PO/OD
SYP GRICILLINCTUS 10 ML PO/TID
PROTEIN X POWDER 1 scoop in 100 ml milk BD
INJ. HAI (6U-6U-6U)
INJ. NPH (6U-X-6U)
SYP POTCHLOR 10ML IN 1 GLASS OF WATER PO/BD
GRBS CHARTING
(BBF , ABF, BL, AL, BD,AD)
7/10/22
S:
Sob improved.
O:
Pt is concious coherent and cooperative
PR-108bpm
RR-22cpm
BP- 140/80mmHg
Spo2-98% in RA
Temp- 97.7
A:? PORTAL HYPERTENSION 2°
P:
IVF NS RL @ UO + 30 ML/HR
Inj. LASIX 120MG/HR IV/BD
CONTINUE ATT
TAB .ISONIAZID 300MG PO/OD w/H
TAB.RIFAMPICIN 450MG PO/OD
TAB.PYRAZINAMIDE 1GPO/OD
TAB ETHAMBUTOL 400MG PO/OD
SYP GRICILLINCTUS 10 ML PO/TID
PROTEIN X POWDER 1 scoop in 100 ml milk BD
INJ. HAI (6U-6U-6U)
INJ. NPH (9U-X-9U)
SYP POTCHLOR 10ML IN 1 GLASS OF WATER PO/BD
INJ. METHYLPREDNISOLONE 500 MG IV BD(DAY-2)
TAB. TELMA 40 MG OD X 3 DAYS
TAB. HCQ 200 PO /OD
TAB. PREDNISONE 20 MG /BD
GRBS CHARTING
(BBF , ABF, BL, AL, BD,AD)
Discussion.
Anti phospholipid thrombolysis
"There were nine thrombotic recurrences (0.05 per patient-year) in seven patients. Six occurred during low-intensity treatment (INR, <1.9)(0.57 recurrences per patient-year), and three occurred during intermediate-intensity treatment (INR, 2.0 to 2.9)(0.07 recurrences per patientyear; P = 0.12). The INRs at the time of thrombosis were 1.42, 1.57, 1.65, 1.72, 1.88, 1.94, 2.22, 2.33, and 2.60. No recurrences were noted for the 110.2 patientyears of high-intensity treatment (INR, >3.0) (P < 0.001).
So maybe >2.5 is just about good enough ?
10/10/22
S:
Sob improved.
O:
Pt is concious coherent and cooperative
PR-79bpm
RR-20cpm
BP- 130/90mmHg
Spo2-99% in RA
Temp- 99
GRBS - 212 mg/dl
A: Extrapulmonary kochs with ATT since 2 months ? MCTD ? SJOGRENS ? systematic sclerosis with nephrotic syndrome (? diabetes ?Lupus )
P:
Inj. LASIX 120MG/HR IV/BD
CONTINUE ATT
TAB .ISONIAZID 300MG PO/OD w/H
TAB.RIFAMPICIN 450MG PO/OD
TAB.PYRAZINAMIDE 1GPO/OD
TAB ETHAMBUTOL 400MG PO/OD
SYP GRICILLINCTUS 10 ML PO/TID
PROTEIN X POWDER 1 scoop in 100 ml milk BD
INJ. HAI (6U-6U-6U)
INJ. NPH (9U-X-9U)
SYP POTCHLOR 10ML IN 1 GLASS OF WATER PO/BD
TAB. TELMA 40 MG PO OD
TAB. HCQ 200 PO /OD
TAB. PREDNISONE 20 MG /BD
GRBS CHARTING
(BBF , ABF, BL, AL, BD,AD)
11/10/22
S:
Sob improved.
O:
Pt is concious coherent and cooperative
PR-103bpm
RR-15cpm
BP- 170/90mmHg
Spo2-99% in RA
Temp- 98.2
A: MCTD ? SJOGRENS ? systematic sclerosis with nephrotic syndrome (? diabetes ?Lupus )
P:
Inj. LASIX 120MG/HR IV/BD
Inj. METHYL PREDNISOLONE 1G/IV/OD
CONTINUE ATT
TAB .ISONIAZID 300MG PO/OD w/H
TAB.RIFAMPICIN 450MG PO/OD
TAB.PYRAZINAMIDE 1GPO/OD
TAB ETHAMBUTOL 400MG PO/OD
SYP GRICILLINCTUS 10 ML PO/TID
PROTEIN X POWDER 1 scoop in 100 ml milk BD
INJ. HAI (6U-6U-6U)
INJ. NPH (9U-X-9U)
SYP POTCHLOR 10ML IN 1 GLASS OF WATER PO/BD
TAB. TELMA 40 MG PO OD
TAB. HCQ 200 PO /OD
TAB. PREDNISONE 20 MG /BD
GRBS CHARTING
(BBF , ABF, BL, AL, BD,AD)
Vitals chart
Urea creatine chart
13/10/22
13/10/22
