1801006023 - 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. 

CHIEF COMPLAINTS

A 37 year old male patient presented with complaints of swelling of face, difficulty in swallowing and change in voice in February.

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 following which the symptoms were 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 of face increases after any H/O trauma.

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. 

Again in 2016, patient was presented with some complaints as in 2007 when emergency tracheostomy was done, patient since then complains of occasional swelling of face, hand and legs which relieved on taking medication. 

In 2021, Patient presented with complaints of swelling of face and difficulty in breathing and was treated with FFP’s, adrenaline, nebulization, hydrocortisone and symptoms got relieved. Patient had around 6-7 hospital admissions in the past 16 years.

Done in 2020 December 

C4 complement serum is less than 8 mg/dl

C1 esterase inhibitor protein is 65 mg/dl

PAST HISTORY 

Not a k/c/o HTN, DM, CAD, thyroid disorders, epilepsy, TB

PERSONAL HISTORY 

Diet is mixed 

Appetite is normal

Sleep is adequate

Bowel and bladder movements are regular 

No addictions 

He is allergic to straw dust,burnt leaves, garbage, plastic smoke,

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

FAMILY HISTORY

No significant family history

GENERAL EXAMINATION 

Patient is concious coherent and cooperative 

Perioral/lip edema present

Facial puffiness present 

Previous tracheostomy scar present on the neck

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

Normal vesicular breath sounds

ABDOMEN

Soft, non tender 

No organomegaly

Bowel sounds heard 

CNS 

Power normal in bilateral upper and lower limbs 

Tone normal in bilateral upper and lower limbs 

Reflexes are normal 

No meningeal signs 

Pupils are reactive bilaterally 

PROVISIONAL DIAGNOSIS 

Angioedema 

TREATMENT

Following treatment was given during the patient’s hospital stay last month:

Inj hydrocortisone 100mg IV stat

Nebulization with adrenaline 1amp stat

Nebulization with budecort tid 

Nebulization with duolin qid 

Patient currently does not use any medication 

Patient used Tab Cetrizine and Prednisone on experiencing similar symptoms

INVESTIGATIONS

These investigations were done during the hospital stay last month 

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+ - 1.11

LFT

TB – 0.89

DB – 0.20

AST- 21

Alt -16

ALP-124

T Protein – 7.3

Albumin -4.59

A/G -1.69

Previous case blog - http://rithikakunapareddy.blogspot.com/2023/02/patient-presented-with-complaints-of.html