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














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