This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

LONG CASE:

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.

Potklor syrup since 3 years

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

Gait video:

https://youtube.com/shorts/dQJa1e6VtcE?feature=share

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:

Sensory system - intact

Motor system -

Less power

Normal tone

No focal neurological deficits

Speech - normal

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

On march 16th

RBS-122mg/dl

Serum magnesium: 2.1mg/dl

RA factor - positive

(48 IU|ml)

Serum calcium-9.2mg/dl

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.

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