48 year old women with multisystem involvement

Name;M.sandhya 
roll no;89
Date; 30 March 2022

This is an 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 patient's 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 the comment box .




48 year old female , resident of Hyderabad and home -maker by occupation, presented to casualty on 14/3/22 .

CHIEF COMLAINTS;

SHORTNESS OF BREATH since 1 week - initially grade -2 later progressed to grade 4 .

PEDAL EDEMA since 1 week

CHEST TIGHTNESS since 1 week

GENERALISED WEAKNESS AND FATIGUE AND FREQUENT FALLS since 1 week

DIFFICULTY OPENING MOUTH AND ORAL ULCERS since 1 week.

DIFFICULTY IN SWALLOWING BOTH SOLIDS AND LIQUIDS since 3 days .


HISTORY OF PRESENT ILLNESS 

Pt was apparently alright 10 yrs ago and went to Hospital in view of headache, easy fatigability and was diagnosed with hypertension and started on medications

6 years ago hospital in view of weight gain and easy fatigability and was diagnosed with Hypothyroidism and is using Thyronorm 50mcg

Later was diagnosed with Rheumatoid arthritis but is not on any medication 

3 months ago diagnosed with DM and is not in medication 

2 months back pt had c/o cough with expectoration, pain in chest region. Was diagnosed as PULMONARY MILIARY TB and started ATT. After 1 month of use she started developing redness and itching all over the body, ATT induced Erythroderma, stopped ATT (1-2-22) for 20 days and again started using 20 days back


20days back after being discharged from a hospital admitted for ATT induced Erythroderma. She is having SOB (grade 2), not associated with any orthopnea/PND, pedal Edema, chest pain, or palpitations.

From 3 days she is having difficulty in swallowing solids and liquids and from 1 day not able to open her mouth because of pain and c/o reddish discolouration of the tongue.

PAST HISTORY;
no similar complaints in the past 
: k/c/o DM since 3 months, (not on medication) 

HTN since 10 yrs 

(On medication)

K/c/o Pulmonary miliary TB on ATT using 3 tablets /day ( HRZE)

K/c/o Rheumatoid Arthritis and not on medication

K/c/o Hypothyroidism since 6 years On Thyronorm 50mcg
PERSONAL HISTORY

Diet- Mixed
Appetite- Reduced
Bowel and bladder- Regular
Sleep- Adequate
No history of any addictions
No known allergies

Family history;

No history of tuberculosis in the family


General examination;

Patient is conscious, coherent, cooperative 
well oriented to time place and person
poorly nourished 

Pallor- present
Icterus- Absent
Cyanosis- Absent
Clubbing-Absent
Lymphadenopathy- Absent
Edema- Present (Non pitting)
Vitals (On admission)-
Temperature- Febrile(Low grade)
Pulse rate- 98bpm)
Respiratory rate- 30cpm
BP- 130/90 mm/Hg
SPO2- 95% at room hair
GRBS- 105 gm%

Head to toe examination;

Alopecia present
Eyes- Proptosis seen
EOM- Intact
Tongue- Red color
Thyroid- No goitre
Skin- Multiple hyperpigmented macules all over the face, upper limbs, lower limbs, abdomen and trunk, skin is dry, thickening of skin noted over the forearms, dorsum of hand, and around the mouth, absent of hair, slight peeling is noted over limbs(both) 
SYSTEMIC EXAMINATION. 

Respiratory system;
  INSPECTION

 Shape of chest- Bilaterally symmetrical
 Position of trachea- Central
 Movements of chest appears to be equal
 No scars and sinuses

 PALPATION

 Movements decreased in left mammary  and Inter scapular area
 Vocal fremitus decreased

 PERCUSSION 

Dull note in left mammary and interscapular
 
ASCULTATION

Decreased air entry on left side
Coarse crepitations heard on interscapular area

Cardiovascular system

S1 and S2 heard
No murmers heard

PER ABDOMEN

Soft and non tender
Bowel sounds are heard

Central nervous system 

No focal neurological deficits

PROVISIONAL DIAGNOSIS 

*Miliary tuberculosis 
*?Erythroderma secondary to ?Isoniazid

INVESTIGATIONS.


Hemogram:

Hb- 7.2 gm%
TC- 15000 cu/mm
MCV- 80.4
MCH- 27
MCHC- 33.6
PCV-21.5
Peripheral smear- Normocytic normochromic
Serum Iron- 45microgram/dl

ABG;
pH- 7.34
PCO2- 18.8
PaO2- 92.4
HCO3- 12.2
SPO2- 96%

LFT;

TB- 2.8
DB- 0.74
AST- 14
ALT- 10
ALP- 673
TP- 7.4
Albumin-2.23

CUE;

Albumin- positive
Pus cells- plenty
Epithelial cells- 1-2

ESR- 180

CRP- 1.2 mg/dl

RA factor- Negative

LDH- 326IU/L

CHEST X RAY.
X RAY NECK- LATERAL VIEW.
ECG.

USG ABDOMEN

HRCT CHEST

TREATMENT 



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