Wednesday, February 2, 2022

33Y/F WITH ARTHRALGIA

 

CBBLE UDHC SIMILAR CASES

 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT


33 year old female came with the chief complaints of :

Arthralgia since 2 months 

Fever since 5 days 

Vomitings and loose stools since 4 days 

Abscess over the right thigh (?ruptured) since 5 days .


HOPI :

Patient was apparently asymptomatic 2 months ago then she developed fever which is of low grade associated with polyarthralgia lasted for 15 days for which she used Tab . Paracetamol , Tab.Diclofenac after which the patient still didn't get any relief 

There's no effect of her symptoms on her daily activities and her occupation.

The patient took COVID vaccine 

H/o small and large joint pains with swelling around the joints 

Due to the persistence of fever and polyarthralgia the patient visited rheumatologist in the month of October (RF -Normal ,HB - 9 g/dl , ESR -110 )

There the patient was advised :

1.Tab .HCQ 200 mg OD for 2 weeks (8pm)

2.Tab.Prednisolone 20 mg OD for 2 weeks (8am)

3.Tab.Azathioprine 50 mg OD in the morning for 2 weeks 

After using these medicines her symptoms got subsided

Today patient has come to our hospital with fever which is of high grade associated with chills and rigors , vomitings - non bilious ,non projectile , food and water as the content , stools - watery in consistency ,large volume mucous , no blood in stools 

No h/o Malena ,hematuria 

Past history :

Not a k/c/o diabetes mellitus , hypertension, asthma ,cad , tuberculosis 

Past surgical history :

Tubectomy done 10 years ago 

Personal history :

Diet -mixed 

Appetite - decreased since 2 months 

Bowel habits - regular 

Bladder habits - urgency present 

Sleep - adequate 

No addictions 

Family history : 

Patient's mother is a known case of diabetes and hypertension since 10 years 

Obstetric history :

Age of marriage - 18

P2L2 

General examination : 

Patient is conscious, coherent,cooperative ,thin built and poorly nourished 

Mild pallor present 


No cyanosis , icterus , clubbing,lymphadenopathy , edema

Mild dehydration present 


Vitals :

Pulse rate - 88 bpm 

Temperature- 100°F

RR - 12 cpm 

BP - 80/50 mmHg 


Systemic examination : 

CVS : S1 S2 + , no added murmurs 

RS :BAE + ,NVBS heard 

CNS : no focal neurological deficits 

P/A :soft , non tender 

        No organomegaly 

        No distension 

        Bowel sounds heard


Local examination of the abscess : 

1 x 1 cm wound present over the anterior aspect of left thigh with surrounding erythema .

Local rise of temperature +

Tenderness +

No pus discharge 

(Diagnosis given by the surgery dept for the abscess - Ruptured sebaceous cyst ) 


Advice given for the abscess :

1.Tab CHYMEROL forte -TID 

2.Tab Hifenac -P PO /BD 

3.Tab Vit -C PO /OD 

4.Regular dressings


Investigations sent on the day patient got admitted : 

1.ECG 


2.USG abdomen - no sonological abnormality detected 

3.RFT : urea - 20 mg/dl , creatinine - 0.7 mg/dl ,Na+ - 146 meq/L , K+ - 4.2 meq/L , Cl- 105 meq/L 

4.LFT : TB - 1.21 , DB - 0.26 , AST - 26 , ALT - 10 , ALP - 95 , TP - 5.9 , Albumin - 3.2 , A/G ratio - 1.22 

5.Hemogram : HB - 8.5 g/dl , TLC - 1,300 , N/L/E/M - 61/27/2/10 , PLt - 1.19 , RBC - 2.90

PCV - 24.1 , MCV - 83.1 , MCH - 29.3 

6.ESR - 85 mm 

7.CUE : Sugar , albumin - nil , pus cells - 3 to 4

E.cells - 2 to 3 

8.Malarial parasite - negative 

9.Chest x-ray 


Previous investigations of the patient :

HB - 9.5 g/dl 

TLC - 2,900

PCV - 28.1 

PLt - 1.89 

K+ - 2.8 


HB - 9 g/dl 

TLC - 4,900 

PLt - 2.69 

R factor - normal 

CRP - 9 

ESR - 10 

Alb - 3.9

TSH - 7.16 micro IU/ml 

USG - free fluid in the pelvis 


Provisional diagnosis :

Acute Gastroenteritis (infective cause ) with ruptured sebaceous cyst with polyarthralgia under evaluation.


Treatment given : 

1.IVF - NS , RL @ 100 ml/hr 

2.Inj Optinneuron 1 amp in 100 ml NS IV/OD 

3.Inj Neomol 1 gm IV SOS (if temp >=101 degree Fahrenheit)

4.Inj Pantop 40 mg IV OD 

5.Inj Zofer 4 mg IV TID 

6.Inj Ceftriaxone 1 gm IV BD 

7.Tab Sporolac -DS PO TID 

8.Tab Dolo 650 mg PO TID 

9. Tab Baclofen 12.5 mg PO SOS ( if hiccups persist )

10.ORS sachets in 1 litre of water - 100 ml /stool. 

11.Tab Redotil 100 mg PO /BD 


Diagnosis : Acute Gastroenteritis (infective cause ) with ruptured sebaceous cyst with polyarthralgia under evaluation with pancytopenia 


Investigations : 

1.Reticulocyte count - 0.5

2.Absolute reticulocyte count - 0.3

3.RI - 0.1 (Hypoproliferative marrow ) 

4.T3 - 0.86 

5.T4 - 10.04 

6.TSH - 7.38

7.Spot protein creatinine ratio - 0.75 


                             SOAP NOTES


AMC bed  1 

S- No fever spikes 

No nausea/vomitings 

O - pt is c/c/c 

Afebrile 

PR-86 bpm

BP - 110/70 mmHg

RR - 20 cpm

SPO2 - 96 % at RA 

CVS - S1 S2 +

CNS - NAD 

RS - BAE + 

P/A - soft , non tender

I/O - 3200/1950 ml

GRBS - 89 mg/dl 


A - Acute gastroenteritis (Resolved ) with ruptured sebaceous cyst with pancytopenia under evaluation 


P- 1.IVF - NS and RL @ 75 ml/hr 

2.Plenty of oral fluids 

3.Inj pantop 40 mg IV OD 

4.inj Zofer 4 mg IV SOS 

5.inj Ceftriaxone 1 gm IV BD

6.tab dolo 650 mg po sos 

7.tab Sporolac -DS po sos 

8.thrombophore ointment for l/a 

9.I/O and temperature charting

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