30 year old female with SOB
This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning and I shall be presenting this case for my Prefinal Practical Examintation. ( 30th March 2022 )
DEIDENTIFICATION : #
The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.
INTRODUCTION :
Here we shall discuss about a patient who is a 30 year old lady hailing from a village in the Southern part of India .
TIMELINE OF EVENTS :
PRESENT COMPLAINTS:
March 15,2022
30 years old female homemaker by occupation was admitted to the General Medicine department with the
CHIEF COMPLAINTS OF :
Cough , dyspnea since the past 4 days , got aggravated the night before.
High grade fever since 1 day.
- B/L joint pains associated with edema over legs from knee to ankle joint including dorsum of foot since 4 days
-
HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic 12 months ago.
Then she developed symmetrical b/l joint pains in the knees which was insidious in on set, gradually progressive, no aggravating factors and relieved on medication i.e. TAB. HYDROXYCHLOROQUINE 200 mg
Associated with morning stiffness.
Around the same time she developed rash and itching over back of neck and upper chest area. As a result of the itching, the area was initially red and turned black.
She also developed rash over the face on cheeks, eyelids
C/O generalised pain.
C/O Difficulty in walking.
C/O distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt,
C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.
C/O vaginal discharge since 10 months. It was initially curdy white which later changed to watery discharge. Associated with itching.
C/O weight loss of 4 kg over the last 10 months.
C/O oral ulcers and genital ulcers since 10 months.
-C/O Dyspnea on exertion (mmrc- 3), gradually progressive since 6 months.
DAILY ROUTINE OF THE PATIENT :
The patient lives in a family of 3 ..(of late the family has expanded) which constitutes her husband ,her mother in law and herself . They follow Islam.
A usual day in her life :
4.40 am : wakes up and bathes
5.00 am : Prayer
5.15 am : She doesn't sleep but lies on her bed and rests for another one or two hours since the work load is not enough in the household to begin her chores at 5 am itself
7.30 am : washes dishes from the last day, washes clothes, makes the morning tea for herself and her family members
9.00am : gets food ready for her husband who goes out for work after breakfast
9.30 am : Serves breakfast for her mother in law and herself
Rests for a while
11.00 am : Prepares for the day's cooking
Rests for a while
12.00 noon : cooks for the day
1.00 pm : Serves lunch for her husband who comes back during afternoon
2.00 pm : Serves lunch for her mother in law and herself
3.00 pm : Rests
4.00 pm : Prayer
5.00 pm : Makes tea for everyone in the house
In the evening mostly all of them sit down and watch television
7.00 pm : Preparations for dinner
8.30 pm : Serves dinner for the family and then for herself
10.00 pm : Sleeps
How the Disease affected and changed her daily life
The disease manifested almost around January last year when she began having joint pains,
At the level of her daily life ,she expresses she began feeling tired and fatigued very easily
Where by after very short spans of work or chores she felt like lying down and taking some rest before the next work ,
Whenever she did a little bit of work , her joints seemed to become " tight " and painful .
The Lassitude was to an extent so much so that she yearned that there was someone who would get everything ready for her and get it for her at bed itself such that she wouldn't have to get up.
Please note : The words have been put just as expressed by the patient such that the intensity and nature of her problem is interpreted better .
NOTE : THIS E LOG SHALL BE PREDOMINANTLY PICTURE BASED .
Menstrual h/o: Age of Menarche : 11 years
Bleeds for 3 days in a 28 cycle, regular , no pains, no passage of clots.
Marital h/o: Marital Life - 14 years, Non consanginous marriage
Primary infertility (Nulligravida)
Has recently adopted a girl from her sister-in-law.
Family h/o: No similar complaints in the family
CLINICAL FINDINGS :
Treatment given in January 2022 :
And 1.tab.wysolone 50mg po od
2.syp.mucaine 10ml/po/tid
3.tab.ultracet 1/2 po/QIT
4.candid cream for L/A is advised
Patient was referred to other health centre for muscle biopsy.
Patient went to health centre,her ANTI NUCLEAR ANTIBODY IMMUNOFLUOTESCENCE showed homogeneous pattern.Intensity 4+ associated antigens involved-ds DNA,histones.
HRCT WAS DONE ON 21/1/22
IMPRESSION: Few patchy areas of ground glass opacities in peri brochovascular distribution-s/o pneumonitis .Corads-4
She didn't undergo muscle biopsy as the doctors there advised it is not necessary
THEY PRESCRIBED:
1.TAB.CALTEN
2.TAB.AUGMENTIN
3.TAB.NAPROXEN SODIUM
4.TAB.FOLVITE
5.CANDID CREAM
6.TAB.WYSOLONE
7.TAB.ESOMEPRAZOLE
8.TAB.SODIUM ALENDRONATE WEEKLY ONCE.
Fever Charting
Chest xrays
Comments
Post a Comment