42 Year old woman with multiple health events since birth
I've 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 a diagnosis and treatment plan.
You can find the entire real patient clinical problem in this link here..
Following is my analysis of this patient's problem:
In my view the order of priority should be given in taking consideration of patients main issues bothering her that problems which she is not worried but need medical attention are as follows
1) Frequent falls to left side.
2) Impairment in cognitive functions.
3) Abnormal sleep patterns.
4) Recurrent edema.
5) Migraines.
6) Psychological issues.
Here from the original history we can assume that the patient expressed her concerns mostly about frequent falls to one side , impaired cognitive functions , Migraines and from the history in my view the medical attention should also be given to abnormal sleep patterns, Recurrent edema, psychological issues.
Probable reasons may be as follows
1)As there are many reasons for frequent falls i tried to correlate problems of patient with certain conditions
# MUSCULAR CONDITIONS- patient has family history of fibromyalgia which maybe manifested in patient resulting in weakness.
#BALANCING ISSUES- which may be associated with cerebellum, inner ear , medications etc
The balancing issues have to be properly evaluated with proper history & clinical examination pertaining to CNS , inner ear conditions like BPPV also have to be ruled out, which is common in patients age group.
#MEDICATIONS - As the patient is taking lot of medications threr may be drug interactions which are causing motor incordination or vasodilation leading to pooling of blood in venous system causing orthostatic hypotension.
2.) Cognitive Impairment is when a person has trouble remembering , learning new things, concentrating or making decisions that affect their everyday life .It may range from mild to severe form. The patient should be assessed for degree of impairment by tests like modified mini mental state examination, three word recall test , cognitive assessment screening test etc.
There is also considerable evidences suggesting that use of H2 blockers like cimitidine can cause cognitive Impairment (Shinohara M, Yamada M. Brain Nerve. 2016;68(4):421‐428. doi:10.11477/mf.1416200415).
3)From the history it is noted that there are abnormalities in patients sleeping patterns they may be caused by patients psychological issues or may be due to any drugs used by patient which are to be carefully studied.
4.) Recurrent Edema can be due to transudate leak,there should be decreased oncotic pressure due to decreased solutes in the plasma (which also explain her edema getting better on talking salt). As the major solutes are plasma proteins synthesized by liver we need to ruleout any liver pathology.
5) we can infer from the history that patient has Migrane attacks which started early in the childhood and got worsened with age so they have to taken care by prescribing proper medications . Migrane can be treated by following classes of drugs Anticholinergic, Triptans ,NSAID , Cartiosteroids .
Careful evaluation of history for triggering factors of migarane should be noted and are to be avoided.
6)The patient had psychological issues in the past like depression , suicidal tendancy etc ..considering them careful monitoring of the patients psychological condition should be done to note any stressors which can trigger the Migranes and can cause sleep disturbances.
Other concerning points from history including excessive hair growth may be a feature of precautions puberty and high intake of salt .
REQUIREMENTS FOR FURTHER EVALUATION
- History of any ear infections and deatiled ENT examination - to rule out inner ear causes of balancing issues .
- Careful monitoring for drug interactions and their effects.
- Complete NERVOUS SYSTEM EXAMINATION ( CNS & PNS) .
- Cognitive function tests - To determine the degree of cognitive Impairment.
- History of triggering factors of migrane episodes.
- Its is also necessary to have further information regarding her Immune panel and any other associated complaints like fever, rash, Her Fluid analysis reports.
- From history we not that she woke up from Surgery two times so we further need information regarding the Anesthesia used and why is the drug less effective in her?
- She also has multiple gene mutations which may result in disturbing several metabolic activites are to be carefully studied.
- CT head to rule out any pitutary tumors and any tumors of inner ear .
- Bilirubin levels .
- Blood pressure readings to study any effect of her high salt intake on blood pressure and to rule out orthostatic hypotension.
In history it is mentioned that
" Thinking cimetidine might be helping which leads me to believe not autoimmune mediated , as cimetidine would make that worse as it boosts immune function."
But there is a considerable evidance suggesting that cimetidine causes down regulation of CD4+ cells and up regulation of CD8+ cells as in most of autoimmune diseases the disease is mediated by antibodies which are secreated by CD4 cells , here they are down regulated by use of cimetidine . So , the presence of autoimmune response cannot be ruled out until proper investigations are made to rule out the autoimmunity.
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