drsaranya: March 2022

I am Saranya ,a final year MBBS student.

Greetings to all my readers;

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.

ACKNOWLEDGMENT

I convey my regards to Dr.Simran Ma'am ( Intern ) , Dr.Nikitha Ma'am ( Intern ) , Dr. Sai Charan Sir ( Resident ,General Medicine )

for helping me ,and guiding me about the case, when the patient came to us 2 months back and also now.

I have taken certain inputs from the elog about this same patient which had been prepared in the past ( link attached herein )

The link to a e log made by me about the same patient has also been attached below.

https://rhea9895.blogspot.com/2022/01/29-years-old-female-with-co-joint-pains.html

http://nikitha0510.blogspot.com/2022/03/dermatomyositis.html

https://drsaranyaroshni.blogspot.com/2022/01/29-year-old-lady-with-joint-pain-and.html

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 :

For the previous sequence of events in the patient please refer to the blog links shared above.

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 itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black.

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.

-she visited many local RMPs,received pain killers as there is no improvement, she visited our Healthcare institution two months back .

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

A quick glimpse of the findings of Dermatomyositis

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.

After presentation in March 2022

Note : Presence of increased facial hair in male pattern since 1 month.

Loss of hair. Aggravated.

Diagnosed with hypertension and Diabetes Mellitus.

Fever Charting

Persistent fever spikes

General physical examination :

Respiratory system examination

Inspection
Symmetrical chest
Decreased air entry on right side
V shaped line seen below the neck

Palpation
Tactile vocal fremitus increased In lower part of right lung

Percussion
Dullness heard over right infrascapular,right inframammary areas other areas are resonant

Auscultation
Normal vesicular breath sounds heard
Decreased air entry in right infrascapular ,right mammary and inframammary areas

Chest xrays

JANUARY 2022 :

MARCH 2022 :

LOWER LOBES CONSOLIDATED.

Sputum culture :

Since patient was having cough with sputum which was moderate in amount and whitish yellow in colour, sputum was sent for culture

Which showed

Sputum culture-presence of branching and filamentous acid fast bacilli are seen? Nocardia species

PROVISIONAL DIAGNOSIS DERMATOMYOSITIS FLARE UP WITH BILATERAL LOWER LOBE CONSOLIDATION & PULMONARY NOCARDIOSIS..

Sensitive antibiotics were started but suboptimal response was obtained hence a doubt was raised if the Nocardia was cultured due to some contamination of the plates , and hence BRONCHOALVEOLAR LAVAGE was done.

Culture reports from the same are still awaited.

LINK TO THE VIDEO OF THE PROCEDURE :

https://youtu.be/Q4L1HcPtI9o

29.03.2022

Primary impression:

Department of Microbiology

thin, long, slender AFB resembling Nocardia seen under microscope from sample of both lungs. Final report is to be awaited.

Even BAL fluid gram stain and zn stain revealed Nocardia in BAL sample of both the lungs (Rt > Lt

Department of Pulmonology :

Thick secretions noted while performing the procedure.

REVIEW OF LITERATURE

: https://pubmed.ncbi.nlm.nih.gov/16224246/

( interstitial lung disease vs. Lung complications in immunocompromised patient under treatment )

https://www.dovepress.com/clinical-features-of-pulmonary-nocardiosis-in-patients-with-different--peer-reviewed-fulltext-article-IDR

( incidence of pulmonary nocardiosis in patients with immune compromise )

I am Saranya ,a final year MBBS student.

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning .

DEIDENTIFICATION :

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Introduction :

Chief Complaints:

The patient being discussed here is a 78 year old lady hailing from the eastern part of India , who presented with the complaints of itching all over her body since 6 months and jaundice since 15 days.

History of presenting illness :

The patient was apparently asymptomatic 6 months ago when she experienced itching all over her body which was insidious in onset and kept increasing gradually , It began on the anterior aspect of the forearm and then kept spreading.

It is also understood that since the itching over her skin began, over the time ,her skin became darker than it was previously.

It was also noted by her family that her appetite had become less and that she had lost some weight as well.

Due to all these findings, 15 days back, on consultation with the local physician, some blood works were done and the Liver function test values were found to be deranged.

Daily Routine :

Even at the age of 78 years , the patient as described by her son is extremely active throughout the day and prefers herself to be self sufficient in all her daily chores.

She gets up in the morning at 5 am ,freshens up, and does pranayaam for 1 hour , next she reads some Holy scriptures for 1 hour , after which she consumes a cup of tea ,

She again engages in Puja related work for another 2 hours after that , and then at around 10 o'clock has breakfast .

The time from breakfast to lunch at around 1.00 pm is spent differently on different days, on sp.e days she reads the newspaper, or engages in conversations with her neighbours,in some other days she goes out and completes some small chores nearby.

After lunch she takes some rest .

In the evening she spends time talking to her family, or watches the television

Has dinner at 9.00pm and sleeps by 10.00 pm

Note : She is a hypertensive on medications since 30 years.

Notes about the patient :