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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.
This is a case of 46 years old female,resident of
nakrekal ,nalgonda district.
CHIEF COMPLAINTS:
Patient was brought with complaints of 2 episodes of
involuntary movements of upper and lower limbs and hemoptysis .
HISTORY OF PRESENT ILLNESS :
PATIENT developed sudden onset movements of both upper and
lower limbs at 5am in the morning which lasted for about 4-5mins , not associated
with any trigger, no aura and the patient was confused after the episode
she had an other similar episode while she was brought to
the hospital.
She had similar episodes at the hospital.
SHE WAS APPARENTLY ASYMPTOMATIC 13 YEARS AGO,
Then she developed low back ache and generalised weakness
started for which she went to local hospital.
Then during the investigations was found to be
having,?soft tissue overgrowth,(as said by attenders ,no documentation)and need
to get operated, during routine investigations creatinine was elevated, then
she was started on conservative management .
(Sod bicarb,Shelcal,Omeprazole,Iron folate)
Since then ,she is on routine followup with hemogram and
serum creatinine levels,and her baseline creatinine levels were 3.2mg/dL.
In june 2022,she developed fever and productive cough
associated with SOB for which CT chest was done,showing peripheral ground glass
opacities,and septal thickening was noted
and few days later , she developed swelling of both
lower limbs till the level of ankles,which were insidious in onset and
gradually progressive
Then underwent dialysis for the first time through right IJV
line,for 4 hours,and was on conservative management.
3 months later, she developed fluid filled bleb, on
one finger and then over all the 10 fingers of hand in 10 days ,some of which
ruptured on their own and some were pricked by the patient.
She developed eroding nails and distorted nails ,
hyperpigmented macules over the face and itching over the palms,and low grade
fever associated with loss of apetite and alopecia.
Ulcers over palms , pulp of fingers associated with burning
sensation
With autoimmune etiology suspicion, she was investigated
further and was ANA profile and was tested Positive for Anti Ro 52and SSA/Ro
60++,and SSB/La+.
In view of the persistent low Hb 5-6g/dL,bone marrow aspiration (from right posterior iliac spine)was done for evaluation of anemia.
Then she was started on mycophenolate mofetil
360mg,and later was planned to shift to cyclophosphamide as she is not
responding to MMF.( But was not started in view of renal insufficiency).
SHE WAS PUT ON MYCOPHENALATE MOFETIL, HYDROXYCHLOROQUINE , OMNICORTIL .
In November she developed cough since 1 week,with whitish
color sputum which is mucoid in consistency and moderate in amount and non
blood stained and non foul smelling .
Bilateral swelling of lower limbs till knee,not
associated with trauma,and decreased urine output for 2 days,and
Shortness of breath( MMRC grade 3),and loss of appetite.
Then ,she was diagnosed as
*?Antisynthetase syndrome
*CLD secondary to autoimmune hepatitis with
hypoalbuminemia *
acute exacerbation of ILD
*recurrent anemia
She did not develop any new skin lesions,oral ulcers.
In December,she was taken to another hospital
Due to increase in the SOB with abdominal distension ,
Then she was taken to second session of dialysis.
Her antibody profile was repeated.
Skin biopsy was done
Bronchoalveolar lavage was performed and was found to be having an infective etiology and mucus plugs in the airways.
On ultrasonography,hypoechoic lesions were found in the liver, PET CT was advised and was done.
So they suspected infective etiology probably
TUBERCULOSIS,and started her on antitubercular therapy
Tab ISONIAZID 300mg daily
Tab RIFAMPICIN 500 mg OD daily
Tab PYRAZINAMIDE 1500 mg thrice a week
Tab ETHAMBUTOL 1200 mg thrice a week
on 15 th December .( But afb, genexpert are all negative)
CURRENT PRESENTATION
2days back she developed sudden onset movements of UL
and lowerlimbs, for 3-4 minutes, associated with blood from
mouth,and there is a brief period of LOC .
similar episode one at 6:00 am, and then 2 similar episodes
after they came here at 8:00am.
At presentation her blood pressure was 170/110 mmhg
Her seizures continued each episode about 2 mins and post
ictal confusion was present.
In view of recurrent seizures CT brain was done.
inj lorazepam was given,
later leviteracetam and
when her seizures weren’t controlled then sodium valproate
was given
She later then had continuous episodes of seizures lasting
for more than 45 minutes .
In view of respiratory distress ( sats 60 ),and
uncontrollable recurrent seizures she was sedated with IV MIDAZOLAM and
intubated.
Post intubation, she had cardiac arrest ( no central pulses
palpable ) 2 cycles of CPR done ROSC was achieved and post CPR monitor showed
monomorphic VT and 2 times 200 J of DC shock was given and then it reverted to
sinus tachycardia.
I examined her on day 2 at our hospital
GENERAL EXAMINATION
Patient is on sedation.
She has hyperpigmentation on the face, upper limbs
Single Bleb on the right hand
VITALS:
Temperature:afebrile
BP 160/110mmhg
Pulse 158bpm
RR 37 cpm
SYSTEMIC EXAMINATION
CVS : S1,S2 heard. No murmurs
RS : Bilateral air entry present
Normal vesicular breath sounds were heard
CNS
Meningeal signs were absent
As the patient is sedated, I didn't elicit Sensory
examination, Motor examination.
Pupils: mid dilated , reactive to light
DOLL'S EYE : present
Reflexes:
SUPERFICIAL:
CORNEAL REFLEX present
CONJUNCTIVAL REFLEX present
DEEP TENDON REFLEXES:
Rt. Lt
Biceps: 2+
2+
Triceps 2+.
2+
Supinator. A.
A
Knee.
A. A
Ankle
A. A
PROVISIONAL DIAGNOSIS:
STATUS EPILEPTICUS, (seizures secondary to hemorrhagic
stroke
?autoimmune vasculitis
? Metabolic cause( increased urea)
Investigations
To summarise this is a case of 46 year old female
with Chronic kidney disease since 13 years, with AUTOIMMUNE INVOLVEMENT ( ANA
positive) -involving Skin, Nails, Lungs, Liver
with current complaints of seizures, due to POSTERIOR
REVERSIBLE ENCEPHALOPATHY SYNDROME.
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