1801006009 - Short 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 32 year old male patient presented with complaints of swelling of face, difficulty in swallowing and change in voice in February.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 16 years back, then in 2007 after exposure to cement dust he developed sudden difficulty in breathing, inability to speak, swelling of face , lips, hands and legs. Emergency tracheostomy was done and treated conservatively following which the symptoms were relieved.
He was found to be allergic to smoke inhalation of burnt plastic, garbage, any offensive smell, strawdust and cotton.
He is also allergic to foods like Brinjal, mutton, fish and papaya.
The symptoms aggravated even on anxiety. Swelling of face increases after any H/O trauma.
Patient used to develop symptoms on and off from the past 16 years. Patient was referred to Outside hospital i/v/o immunotherapy in 2011 and was treated with some unknown medication and was advised precautionary measures against allergens.
Again in 2016, patient was presented with some complaints as in 2007 when emergency tracheostomy was done, patient since then complains of occasional swelling of face, hand and legs which relieved on taking medication.
In 2021, Patient presented with complaints of swelling of face and difficulty in breathing and was treated with FFP’s, adrenaline, nebulization, hydrocortisone and symptoms got relieved. Patient had around 6-7 hospital admissions in the past 16 years.
Done in 2020 December
C4 complement serum is less than 8 mg/dl
C1 esterase inhibitor protein is 65 mg/dl
PAST HISTORY
Not a k/c/o HTN, DM, CAD, thyroid disorders, epilepsy, TB
PERSONAL HISTORY
Diet is mixed
Appetite is normal
Sleep is adequate
Bowel and bladder movements are regular
No addictions
He is allergic to straw dust,burnt leaves, garbage, plastic smoke,
He is also allergic to foods like Brinjal, mutton, fish and papaya.
FAMILY HISTORY
No significant family history
GENERAL EXAMINATION
Patient is concious coherent and cooperative
Perioral/lip edema present
Facial puffiness present
Previous tracheostomy scar present on the neck
Vitals:
Temperature 98.6F
Pulse rate 106bpm
Respiratory rate 18per min
BP 110/70 mmhg
Spo2 98 at room air
GRBS 110mg/dl
SYSTEMIC EXAMINATION
CVS
s1s2 heard
No murmurs
RS
Bilateral air entry present
Normal vesicular breath sounds
ABDOMEN
Soft, non tender
No organomegaly
Bowel sounds heard
CNS
Power normal in bilateral upper and lower limbs
Tone normal in bilateral upper and lower limbs
Reflexes are normal
No meningeal signs
Pupils are reactive bilaterally
PROVISIONAL DIAGNOSIS
Angioedema
TREATMENT
Following treatment was given during the patient’s hospital stay last month:
Inj hydrocortisone 100mg IV stat
Nebulization with adrenaline 1amp stat
Nebulization with budecort tid
Nebulization with duolin qid
Patient currently does not use any medication
Patient used Tab Cetrizine and Prednisone on experiencing similar symptoms
INVESTIGATIONS
These investigations were done during the hospital stay last month
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