A 42 year old female with multiple health ailments.

Laxmiraj Bangari 22

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 a diagnosis and treatment plan


You can find the entire real patient technical problem in this link here:
https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1


The problems in order of priority are:

1. Headaches

2. Swelling

3. Left sided weakness

4. Sleep deprivation.

5. Fatigue due to exercise.


Reasons for the problems are:


1.Headache.

  • Headaches started in very young age and became worse with menses at 14 and when she used hormonal contraceptives like nova ring( release oestrogen and progesterone).
  • These are migraine attacks which got severed later on.
  • Sometimes they are preceded by aura. 
  • Earlier I thought it was just an prementrual headache. Mentrual migraine they called.
  • But later it is concluded as migraine.
Migraine
 Migraine are episodic are episodic and are associated with aura.
  • Diagnostic criteria for migraine:

  1. Aggravated by movement.
  2. Throbbing pain
  3. Unilateral
  4. Moderate to severe intensity.

  • Characteristics of aura seen :
  1. Gradual onset 
  2. Lasting for less than 1 hr
  3. Self resolving
Treatment for migraine
  • Triptans 

Swelling 
 It started at age 2 and patient swells in face  , neck , abdomen. In conditions like emotional stress, exercise , smoking.

It may be due to haemolytic crisis in patient due to G6PD deficiency.

G6PD deficiency

It is an x linked resessive disorder, it is a key enzyme in HMP shunt pathway, it is required to produce NADPH that is used to synthesis GLUTATHIONE. glutathione is an antioxidant. That neutralises the oxidising part of H2O2. In case of absence of this NADPH the oxidant loses the RBC cell membranes . Thus he players occurs intravascular.

Triggers for hemolysis

Drugs: sulfonamides , quinine, aspirin, dapsone .
Infections
Favism it’s called: reaction to fava  beans.

 Symptoms:
 Hemoglobinuria, dark urine, anemia ,backpain,  vomiting swelling,.

Investigations

Peripheral smear shows Heinz bodies , bite cells.
Coombs rest is negative , as it is not an autoimmune haemolytic anemia .

Treatment

Avoid triggers.

 Blood transfusions for support.

Left sided weakness

Numbness in left hand and left side of face started at 34 years.

 Possibly due to Hemiplegic migraine 

This is associated with spinning sensation.

 According to history she also felt a tight mass feeling between her neck and jaw, but imaging shows it clear , no pathology or abnormality detected.

 Sleep deprivation 

 Sleep is deprived since her very young age she used to sleep only 2 to 4 hours.

 Causes: NADPH , low glycine and AMDP 1 deficiency.

 Treatment not known. L serine known to act like glycine and improves sleep.

 Fatigue due to exercise 

AMDP 1 deficiency might be cause. Because excess of adenosine causes fatigue and dullness, exercise intolerance, muscle pain muscle cramping are seen.

  Treatment:
 Ribose daily is source of energy.

 Genetics

 MTHFR( METHYLENE TETRAHYDROFOLATE REDUCTASE ) MUTATION.

 Increased homocysteine levels, decreased folate and b12 levels.
 Associated with digestive issues, migraines, depression, scoliosis, peripheral neuropathy. 

 Treatment : 
Folate , vit b12, methionine, and 5 MTHF.

 WNK mutation

 It is serine threonine kinase which helps in regulation of action chloride cobtransporters.
 It is familial hyper kale ice hypertensive syndrome.

 Hair loss

 Degeneration of cervical spine , hip .

 It may be spondylosis or juvenile idiopathic arthritis...
Resources

 https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1
Davidson principals of medicine
Dr. Ryan medicine modules.
Wikipedia 
www.webmd.com
https://www.egl-eurofins.com





Comments

Post a Comment

Popular posts from this blog

NEPHROTIC SYNDROME WITH TYPE -I DM, HYPERTENSION,RIGHT PLEURAL EFFUSION

Image
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 A 20 yrs old female who is a house wife was brought to the casualty with the C/O decreased urine output since yesterday  Swelling all over the body since 4days History of presenting illness: Patient was apparently asymptomatic 2 months back then she developed swelling of both legs and face, and got admitted in the hospital got treatment and discharged.4days back she had no urine output and swelling all over the body. Past history: K/c/o T1DM On examination Patient is conscious coherent and...
Read more

36M with diabetic neuropathy

Image
  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 C/o Weakness in both upper and lower limbs since 6months Slurring of speech since 5 years Hopi: Patient is apparently symptomatic 5 years back then he developed stiffness in neak  And headache while carrying heavy weights on his head as his daily routine work . After 1 year he developed progressive weakness in arms and reached to a stage where he couldn’t lift a glass of water( according to patient). Weakness progressed to lower limbs in 1 year reached to a stage where he couldn’t get up...
Read more

65 yr old male pt AKI ON CKD 2° TO HTN

Image
  Cheif complaints: A 65year old man came to hospital with complaints of fever on and off , tightness of abdomen ,facial puffiness since 15 days   History of present illness:  A 65 year old male toddy tree climber by profession was apparently asymptomatic 10 years back then he was had swelling and pain abdomen for which he was diagnosed with- lt sided inguinal hernia and got operated in some private hospital. Preoperative and postoperative period was uneventful  4 years back patient had complaint of giddiness for which he approached government hospital physician and was diagnosed Hypertension[170/90] and was started on some unknown medication  6 months back patient had complaint of bilateral pedal edema for which investigations were done and found his serum creatinine elevated (4.3 ) and proteins in urine  CT scan showed unilateral (lt)staghorn renal calculi and bilateral inguinoscrotal hernia  DTPA scan was done showing decreased GFR on left side( 12%...
Read more