A 42 yrs old women clinical analysis

Presented by : Ranjeeth kumar reddy

Roll no : 119 ( 8th sem)

I have been given this case to solve in an attemot to understand the topic of "patient clinical data analysis"to develop my competency in reading and comprehending clinical data icluding history,clinical findings,investigations and come up with a diagnosis and treatment plan.

Lab reports - https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 for detailed lab reports. And more detailed history. 

 So, according to the history above the problems in order of priority I found are:

Swelling of the body

Left side going numb. 

Rash on face

Severe headaches

Sleep deprivation 

Oliguria

1.Swelling :  she's diagnosed as hemolytic anemia patient, G6PD deficiency can cause congestive heart failure which could be the cause of shortness of breath  and kidney failure due to which probably she might have developed swelling and fatigue due to oxidative stress.Shortness of breath can be even caused due to hiatus hernia. G6pd deficiency G6pd catalyzed the rate limiting step in pentose phosphate pathway and generates NADPH which in turn produce glutathione which protects against oxidative stress.  Generally such patients develop congenital hyperbilirubinemia and may be this patient had jaundice at her birth.  Triggering factors include: fava beans hence after consumption she had even more swelling and increased bp ,drugs like sulfonamides and antimalarials. and since she has decreased nadph and ATP she has loss of ions. Decreased urination and facial edema. 

Investigations done:

Complete blood count -anemia 

Ast and alt -increased 

Chest-x-ray-left atrial enlargement

Ecg -right heart enlargement
Echocardiography

Investigations recommended:

Lactate dehrogenase (ldh) level

Serum haptoglobin level 

Peripheral blood smear

Treatment- she has taken cimetidine to reduce her swelling. It has worked but she developed sweating after its use. Ribose taken to reduce fatigue as it helps in production of ATP. 

My recommended treatment-remove the underlying cause. If required blood transfusion and oxygen therapy to be given. 

2.Rash - since she's diagnosed as behcets syndrome patient ,due to the autoimmunity towards the blood vessel it leads to vasculitis which includes development of rash, blurred vision (which probably explains failed lasik)

Triggering factors -stress, menstruation, other skin and oral trauma can aggravate the symptoms. 

Diagnosis - by signs and symptoms 

Recommended -pathergy test or skin prick test. 

3.sleep disturbances - 

G6pd deficiency impairs glycolysis metabolism hence there's decreased formation of glycine. 

Treatment -L-serine which acts like glycine and induces sleep after which the patient has improved the timing of her sleep. 

4.Headaches(migraines with Aura) 

The exact cause of migraine is to be evaluated. It is associated with Aura and left sided numbness , mild memory loss, stuttering of speech and nausea and vomiting. 

Differential diagnosis - 

Migraine

Secondary headache - transient ischaemic attacks

Giant cell arteritis

Toxic and metabolic causes

Brain neoplasms

Thunderclap headache 

Stroke

Csf pressure related secondary headaches

Probable investigations 

Csf analysis 

CT scan 

MRI of brain

EEG 

Treatment taken:

Triptamines ,Nattokinase which has brought great change in her symptoms. 

Treatment recommended:

Suggest her to stay in a dark room. 

Avoid triggering factors like drugs, stress. etc and advice treatment of triptans , Acetaminophen, ergots and antiemetics.

5.Oliguria: it is probably believed to be caused due to oxidative stress occurring in G6PD deficiency  which explains reduced NADPH production and loss of ions causing decreased urination associated with dark color urine

Other causes of oliguria:

Physical trauma

Infections

Shock

Investigations recommended:

Urine output 

Urine examination

Ultrasound /CT abdomen

Blood tests 

Cystoscopy

Treatment recommended: 

Increase fluid intake

If infections -treat with antimicrobials

Diuretics (but no influence on the patient) 

Evaluation as to why patient developed left side numbness is to be done.