60 kanumilli kundana

40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS

December 06, 2023

40 YEAR OLD FEMALE WITH PERIORBITAL PUFFINESS

** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.

I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

CASE :

Chief complaint:

-Puffiness around eyes since 2months

-Tingling all over the head since 2 months

- shortness of breath since 2 months

-joint pains since 2 months

History of present illness:

Patient was apparently symptomatic 2 months ago then she developed puffiness of eyes aggravating with work and cold temperature , revealing on taking rest.
Not progressing, no diurnal variations.
Patient chief complaint of tingling all over the head since 2 months aggravating with sleep. No relieving factors.
Patient had neck pain since 2 months and restriction of movement
Patient complaints of difficulty breathing. Aggravating with mild daily routine activities , No seasonal variation, no allergies
Patient complaint of Body pains Over the large joints Since two months, no history of abdominal pains burning micturItion deviation of mouth, squint , dysphagia

Daily routine:

Patient wakes up at 5:00 am
She makes tea for herself and her son and have at 6:00 am
She will do all household work works and prepare lunch till 9 am
At 9 am she will have rice and some curry as breakfast
she will go to work i.e plucking cotton (harvesting) after having breakfast
At 2pm she will have her lunch rice and curry
She will have dinner at 8:00 pm with rice, curry and curd
She will go to sleep by 9:00 pm

- patient is explaining about her stress conditions like:she lost her husband 20 yrs ago from then she is the only person earning in her family , she herself with some money managed her daughter to get married later on after some disputes with her husband she came back to her mother’s house and her daughter is also staying with her.

-Her son completed intermediate he is not willing to do any job or any daily works inspite of all the difficulties his mother facing

-patient is so worried about both her children and to clear the debts she took from family for daily needs as she earns 150 rupees if she goes to work so in a month she will earn only 2000 /-

- By this we can understand the situation of the patient about her family and financial problems.

Past history:-

Not a known case of DM,HTN,EPILEPSY, CVD,CAD

past history of trauma to left temporal side of head

Personal history:

Married, daily wage worker

Normal appetite , regular bowel and bladder movements

No allergies

no addictions

Family history: Not Significant

Menstrual history:

Age of menarche: 13 yrs

LMP : 1/12/23

OBSTETRIC HISTORY:

Age at marriage:7 yrs

age at 1st child birth:19yrs

G2P2

General examination:

Patient is conscious coherent cooperative

Pallor present

No icterus, cyanosis, clubbing, lymphadenopathy, malnutrition, dehydration

Vitals:

Temperature 98°F

Pulse rate: 84 bpm

Respiratory rate: 22cpm

Blood pressure: 100/60mmHg

SpO2 98%

CDSS

Rakesh Biswas sir: Did she have neck pain?

Kundana : Yes sir

Rakesh Biswas sir: Why is it not mentioned anywhere in the case report? Since when?

Rakesh Biswas sir: "past history of trauma to left temporal side of head"When?

Lahari : 10 yrs back sir

Rakesh Biswas sir: Add the duration to the case report!! Since when is neck pain?

Lahari : Since 2 months sir

Rakesh Biswas sir: In her daily routine share the details about her household work and share how the neck pain has disrupted her household work since two months and also how her other symptoms have disrupted her daily activities

Rakesh Biswas sir: What is her work from 2PM to 8 PM?

Rakesh Biswas sir: "complaints of difficulty breathing. Aggravating with mild daily routine activities"What are those mild daily routine activities? What about other moderate activities? What has happened to her activities since 2 months?

Rakesh Biswas sir: Where is the musculoskeletal examination?

Rakesh Biswas sir: "Patient complaint of Body pains over the large joints since two months"Which joints?

Kundana:When she does work like plucking cotton from morning to evng puffiness around eyes would increase sir when she takes rest it resolvesCervical area and backache sir

Rakesh Biswas sir: Exposure!!

Can cotton exposure cause this as a hypersensitivity angioedema?

Kundana: But she is doing this job from past 20 yrs sir..

Rakesh Biswas sir:But since when is she working with cotton? Has there been any change in the way she was working with cotton earlier and since two months?

Kundana:No sir

She told she had many stress factors about her family and financially

Lahari:Not only cotton sir seasonal crops also she is doi6

Rakesh Biswas sir:Share the details about her stress

Lahari: Her son is not working and forcing her to give money for his expenses

Her daughter is married but she is staying with her due to disputes with her husband

Looks like she is the only source of income in her family

And she had some loan sir

Rakesh biswas sir: How old is her son. Share more about him and why he's not working

How when and why did she take a loan

Lahari:Her son is 18yrs old

He completed intermediate and

Not willing to study further or do any work

She took loan for her crop expenses sir

Rakesh Biswas sir:So tell us in detail about her farming!!

You only told us that she's a daily wage cotton plucker!!

Kundana : Sir she earns daily 150-200 if she goes to work or else no source of income she took loan from family members for her daily needs

Rakesh Biswas sir: Add all the above conversations to the case report

Yesterday's lab results driven diagnosis can also explain her heart failure symptoms

Kundana: Even ultrasound report came sir

Rakesh Biswas sir: Does it reveal anything better than the lab report?

Kundana: it shows features of thyroiditis

Manisha mam:https://www.bmj.com/content/364/bmj.l279

Rakesh Biswas sir:What are the ultrasound features of thyroiditis? What is the sensitivity specificity of those feature in diagnosing thyroiditis?

Kundana:

diffusely enlarged thyroid gland with a heterogeneous echotexture is a common sonographic presentation (especially initial phase)
the glands may be atrophic and small in chronic cases
the presence of hypoechoic micronodules (1-6 mm) with surrounding echogenic septations is also considered to have a relatively high positive predictive value 3,4; this appearance may be described as pseudonodular or a giraffe pattern
color Doppler study usually shows normal or decreased flow, but occasionally there might be hypervascularity similar to a thyroid inferno
the hypervascularity does not reflect thyrotoxicosis; indeed it appears to be more common in hypothyroid Hashimoto patients 11
prominent reactive cervical nodes may be present, especially in level VI, With normal morphology.

USG had high specificity (90%) but low sensitivity (35%) for the diagnosis of thyroiditis. Thus, USG does not appear

Manisha mam:https://bjbas.springeropen.com/articles/10.1186/s43088-022-00197-0

Rakesh Biswas sir:Did our patient have any of these ultrasound findings?

Are these matching your literature review?

Lahari:USG findings: Altered echotexture and increased vascularity present sir

Kundana:Yes sir echogenicity and enlarged lymph nodes are present with increased vasculature

Systemic examination :

CVS:

S1 , S2

no murmurs

no thrills

Respiratory system: