13 yr old with auto immune

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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 and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.

A 13 year old female student came to the opd with

CHIEF COMPLAINTS:

- Shortness of breath since 4 days

- Vomitings since 2 days

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic till the age off 11 that is in 2020, she pursued her studies residing in a hostel where she noticed development of multiple neck swellings which were bilateral and also had a complaint of cough and fever which were on and off. For which she was referred to the RMP.

Since she has a mother with a history of tuberculosis, she was initiated with ADT which she followed for two months starting from 2021 June after which she developed a fever so the ADT was stopped and was referred to Hyderabad.

In Hyderabad, the patient was evaluated for cough but none of the investigations showed AFB.

In the same period she developed wrist joint pains and knee paints, for this there was a suspicion that it might be an autoimmune disease and was started on the tablet wyslone and HCQ which she used for 15 days and stopped.

Later she again developed joint pains, facial puffiness, pedal oedema, fever and cough.

In the same period, lymph node biopsy was done (report unavailable), GeneXpert showed rifampicin resistant TB.

ANA profile positive for dsDNA.

So she was initiated on ADT empirically on may 2022. Before starting ADT, she noticed facial rash and hair loss. Now she has come with history of SOB ( grade 2-3) and vomiting which were non projectile, non bilious, 4 episodes till date containing ingested food as content.

PAST HISTORY

Not a known case of Diabetes, hypertension, epilepsy, CAD, asthma

NATAL HISTORY

Second degree consanguinity present.

She was a first child born in 201o, LSCS delivery.

Immunization history unknown to the father.

FAMILY HISTORY

Mother was a known case of tuberculosis, diagnosed in 2014. She died in 2022 September ( did not use ADT regularly )

PERSONAL HISTORY

Diet: mixed

Appetite: decreased

Bladder: urine reduced

Sleep: adequate

No addictions

TREATMENT HISTORY

Used ADT for 6 months then discontinued

GENERAL EXAMINATION

Patient is consious, coherent, cooperative, well oriented to time, place and person. Moderately built and moderately nourished.

Pallor present

Edema present in the lower limb which was of pitting type

No cyanosis, icterus, clubbing, lymphadenopathy

VITALS

Temperature: 98.4 F

PR: 126 bpm

BP: 130/90 mmHg

RR: 26 cpm

Sp02: 98%

SYSTEMIC EXAMINATION

Patient is examined in a well lit room, in the sitting position.

RESPIRATORY SYSTEM:

BAE (+)

Vocal resonance reduced in affected areas

Dull note in affected areas

CARDIOVASCULAR SYSTEM

S1, S2 heard

Pericardial rub heard

No murmurs

PER ABDOMEN

Free fluid present

Tenderness in right and left hypochondria and epigastrium

CNS

Higher mental state:

Consious, coherent, cooperative, well oriented to time place and person.

Cranial nerve examinations: normal

Motor system:

RT LT

Biceps ++ ++

Triceps 2+ 2+

Supinator + +

Knee 2+ 2+

Ankle + +

CLINICAL IMAGES

INVESTIGATIONS

1. CRP: negative

HAEMOGLOBIN	# 6.8 gm/dl
TOTAL COUNT	5,400 cells/cumm
NEUTROPHILS	62%
LYMPHOCYTES	34%
EOSINOPHILS	1%
MONOCYTES	3%
BASOPHILS	0%
PCV	# 23.3 vol %
MC V	# 77 4 fl
MC H	# 22.6 pg
MCH C	# 29.2 %
RDW-CV	# 20.1 %
RDW-SD	57.8 fl
RBC COUNT	# 3.01 millions/cumm
PLATELET	1.20 lakhs/cu.mm