1801006073 - Long case

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I have 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 diagnosis and treatment plan

CHIEF COMPLAINTS:

A 40year old female came to OPD with chief complaints of 

Body pains since 6months

Weakness of lower limbs since 6months

Difficulty in walking since 6months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3years back than she developed weakness in left lower limb which is sudden in onset and gradually progressive in nature for which she consulted a local doctor where she was found to be having low potassium levels. She was kept on potassium supplements then the weakness got resolved.

Later in Nov 2021 she had an episode of upper and lower limb weakness with loss of consciousness and loss of speech for 2 days.She also has history of decreased bowel and bladder movements .She was again diagnosed with hypokalaemia for which she was supplemented with potassium and was on ventilation.

1 unit of blood transfusion was done than she got recovered within 5days.

In may 2022 she has similar complaints as past but it is less severe.She was again treated for hypokalaemia and got recovered within 3 days.

In Feb 2023 she has similar complaints as past with history of 2 episodes of vomiting which is non bilious ,non projectile and food particles as content.After she got admitted into hospital she noticed a swelling at parotid region on left side and dry mouth for which she was referred to dental where medication was given and swelling got subsided.Then biopsy was taken from the lower lip.

She also has dry eyes with burning sensation , dry skin with no itching.

Then in march 2023 when she came for follow up ,she was referred to ophthalmology and orthopaedics department.

At present she has body pains and difficulty in walking.

No history of fever ,cough ,itching ,numbness and tingling sensation ,complexion changes ,dental caries and oral thrush.

PAST HISTORY:

Not a known case of Diabetes, Hypertension,Asthma ,TB ,epilepsy, CAD

DRUG HISTORY:

She was on anti rheumatoid drugs and potassium syrup since 3years.

FAMILY HISTORY:

No significant family history.

PERSONAL HISTORY:

She used to work as a daily wage labourer but stopped working 3years back due to weakness.

Appetite: normal

Diet : mixed

Bowel and bladder movements: regular with medication

Sleep: adequate

No addictions

GENERAL PHYSICAL EXAMINATION:

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

Moderately built and nourished

No signs of pallor , icterus , cyanosis ,clubbing , lymphadenopathy ,pedal edema.

VITALS:

Temperature:Afebrile

Blood pressure: 110/70 mmHg

Pulse rate: 88bpm

Respiratory rate: 18cpm

SPO2:90

SYSTEMIC EXAMINATION:

CVS: 

No visible pulsations, scars, engorged veins.

 No rise in jvp 
Apex beat is felt at 5 Intercostal space medial to mid clavicular line.

 S1 S2 heard . No murmurs.

RESPIRATORY SYSTEM:

Shape of chest is elliptical, b/l symmetrical.

Trachea is central. Expansion of chest is symmetrical
 Bilateral Airway Entry - positive
 Normal vesicular breath sounds

ABDOMEN: 

On inspection - abdomen is flat & symmetrical 
Umbilicus is central  and inverted
No scars, sinuses & engorged veins seen.
All 9 regions of abdomen are equally moving with respiration
On palpation - abdomen is soft and non tender
On percussion - no shifting dullness, no fluid thrill
On auscultation - normal bowel sounds are heard

CNS:

GCS - E4,V5,M6

Sensory system - intact

Motor system - intact 

Cranial nerves - 

5th sensory - intact 

       motor - intact 

7th  motor - normal facial expressions 

       sensory -normal taste sensation 

       corneal & conjunctival reflex - present 

       secretomotor - decreased moistness of eyes, tongue , buccal mucosa 

8th - intact 

Finger nose incoordination - no 

Heel knee incoordination - no

Sensory system - intact

Motor system examination -

Tone - normal

Power - reduced 

PROVISIONAL DIAGNOSIS:

Recurrent hypokalaemic paralysis

Secondary to distal Renal tubular acidosis

Sjögren’s syndrome 

Rheumatoid arthritis?

INVESTIGATIONS:

Serum electrolytes on 1/2/23

Sodium:142mmol/L

Potassium: 1.8mmol/L

Chloride:108mmol/L

Serum calcium:9.8mg/dl

Serum creatinine:1.3mg/dl

Blood urea:29mg/dl

Urinary calcium:3.0mg/day
Spot urine sodium:60mEq/L
Spot urinary potassium:12.0mEq/L

On march 13th

Hb:9.6g/dl

ESR:30mm/hr

Serum creatinine:1.1mg/dl

Serum potassium:4mmol/L

SGOT:23IU/L

SGPT:16IU/L

On march 15th

ESR:36mm/hr

Serum sodium:139mmol/L

Serum potassium:3.06mmol/L

Serum chloride:114mmol/L

Complement C3:114mg/dl (90-180mg/dl normal)

Complement C4 :63mg/dl (10-40 mg/dl normal)

Serum creatinine:0.99mg/dl

SGOT: 15IU/L

SGPT:11IU/L

BIOPSY REPORT:

Histopathological Findings:

 H and E stained section shows the presence of multiples lobules of minor salivary gland tissue consisting of normal appearing mucous acini with intralobular and interlobar ducts. The salivary gland tissue also shows the presence of multiple foci (25) of

lymphocytic infiltrate, endothelial lined blood vessels and hemorrhagic areas .

Correlating with clinical features, the above histopathological features are suggestive of Sjögren’s syndrome.

Treatment

Tab nodosis

Syrup potklor 15 ml/po/tid

Tab pregaba M 75 mg

Tab pantop

Tab HCQ200 mg 

Tab prednisolone.