This is a de-identified open-online-patient-record with initial information in patient's voice, posted here december 2016 after collecting informed patient consent (form downloadable here) by BMJ Elective Student.
Patient history by author -__
38 year old woman from ******* currently on hemodialysis in our hospital for renal failure.
She has been having a struggle life since 1995 when her mother passed away due to a medical condition ( reason not known by the patients husband) who was a known diabetic and a known hypertensive. In 1998, her father passed have because of an unknown cardiac condition. She got married in 2000 to her husband who works at a rice mill industry. She has 2 daughters, the elder daughter is 19yrs of age and currently in her btech 2nd year, 2nd daughter is 17yrs old and is in her inter 2nd year.
In 2006 she paid a visit to her dentist for getting a rootcanal done that was when she got diagnosed with type 2 diabetes mellitus and was put on Tab Zoryl 2mg BD. She has been switching from Tab Zoryl 2mg to 1mg depending on her blood sugar levels on her own .
6 yrs back, her husband had to sell their *** store ****** because of road construction work, since then her husband says she has been more stressed and she would randomly throw tantrums It had got to such a point that she would throw objects aggressively at others and over the past 5 years she has also been having visual and auditory hallucinations. She was taken to a psychiatrist in **** ( hospital) and the doctor there started her on tab Sizodon Forte ( risperidone and trihexyphenydryl ) and Tab Dayo 250mg ( Divalproex) and they even consulted a neurophysician who advised for a CT brain which turned out to be normal. She got diagnosed to be a hypertensive 3 yrs back and has been using Tab metxl 25mg once daily on and off since then.
One and a half years back she consulted an obstetrician since she had amenorrhea since 3 months, her husband says that he even found her to be pale then and on routine investigations she got diagnosed with renal failure with a serum creatinine of 5mg/dl and Sr urea of 70mg/dl for which they consulted a nephrologist who started her on sodium bicarbonate and calcium supplements.
1 month back she presented to our hospital dyspneic with bilateral pedal edema extending to her thighs for which she was started on hemodialysis.
Day1 post admission
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Day 3 post admission
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Day 4 post admission
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Patient history by author -VV
38yr old woman
Renal failure on MHD
S - Complaining of non productive cough and aggravated dyspnea since last night.
She also complains of feeling febrile since last night.
O - Patient is pale and bilateral pedal edema present
Patient appears to be in respiratory distress
- PR-99bpm
BP- 120/80mmhg
Spo2-98% at 2 litres of oxygen
RR-24cpm
Cvs -S1 S2 present
Lungs- bilateral inspiratory crackles present
Abdomen-distended with everted umbilicus
A- ckd on mhd
Type 2 diabetes since 15 years on medication
Htn since 3 years
Schizophrenic since 5 years
? Pulmonary koch’s / ? Septic emboli
P- 2D ECHO in view of any infective endocarditis changes
Sputum for cbnaat to be sent
Coagulation profile to be sent
Debate on whether to start on antitubercular therapy
Conversational Learning/CDSS -
AT- Palpable skin lesions with Cavitary lung lesions and rapidly progressive renal failure. All roads lead to Rome (GPA in this case ?)
RB- Someone still has to carve out a generous amount of lung tissue from her to prove that Rome exists? 😅
AT- In an ideal non covid world, yes sir. However, a skin biopsy with cANCA titres would be helpful here.
RB- Or can we take a short cut to Rome through her skin tissue which would be more easier? 🤔
AT- What would you expect in the skin biopsy that would take us to Rome conclusively?
AT- Necrotizing granulomatous vasuclitis. I think I saw rim enhancement of the cavity walls in the CT and also the renal lesion appears aggressively active. Some system 1 learning says cANCA in active inflammatory lesions is strongly positive and suggests a small vessel vasculitis, particularly GPA.
RB- What would be the sensitivity and specificity of this finding?
Enough to consider immunosuppresives over Sepsis treatment as both are antithetical to each other
AT - Even a renal biopsy showing pauci immune glomerulonephritis can help. Will share some system 2 data.
AT - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5059091/#!po=0.943396
Between February 1, 2005 and February 1, 2015 a total of 8403 IIF for ANCA was performed of which 1238 tested positive (27% p-ANCA, 71% c-ANCA pattern, 1% aspecific pattern) in 279 patients. A total of 5370 immunoassays for PR3 and/or MPO ANCA was performed of which 1218 samples tested positive in 239 patients (Fig.1)
RB - Can we fit our patients to any of the patients in the study you quoted here?
What are the attributes she shares with them?
AT-
- The table explains quite a lot. Patients were initially diagnosed on clinical features and then ANCA samples were sent for.
RB - Looks reassuring.
DV -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014960/
Patient history by author -__
38 year old woman from ******* currently on hemodialysis in our hospital for renal failure.
She has been having a struggle life since 1995 when her mother passed away due to a medical condition ( reason not known by the patients husband) who was a known diabetic and a known hypertensive. In 1998, her father passed have because of an unknown cardiac condition. She got married in 2000 to her husband who works at a rice mill industry. She has 2 daughters, the elder daughter is 19yrs of age and currently in her btech 2nd year, 2nd daughter is 17yrs old and is in her inter 2nd year.
In 2006 she paid a visit to her dentist for getting a rootcanal done that was when she got diagnosed with type 2 diabetes mellitus and was put on Tab Zoryl 2mg BD. She has been switching from Tab Zoryl 2mg to 1mg depending on her blood sugar levels on her own .
6 yrs back, her husband had to sell their *** store ****** because of road construction work, since then her husband says she has been more stressed and she would randomly throw tantrums It had got to such a point that she would throw objects aggressively at others and over the past 5 years she has also been having visual and auditory hallucinations. She was taken to a psychiatrist in **** ( hospital) and the doctor there started her on tab Sizodon Forte ( risperidone and trihexyphenydryl ) and Tab Dayo 250mg ( Divalproex) and they even consulted a neurophysician who advised for a CT brain which turned out to be normal. She got diagnosed to be a hypertensive 3 yrs back and has been using Tab metxl 25mg once daily on and off since then.
One and a half years back she consulted an obstetrician since she had amenorrhea since 3 months, her husband says that he even found her to be pale then and on routine investigations she got diagnosed with renal failure with a serum creatinine of 5mg/dl and Sr urea of 70mg/dl for which they consulted a nephrologist who started her on sodium bicarbonate and calcium supplements.
1 month back she presented to our hospital dyspneic with bilateral pedal edema extending to her thighs for which she was started on hemodialysis.
Day1 post admission
-
Day 3 post admission
-
Day 4 post admission
-
Patient history by author -VV
38yr old woman
Renal failure on MHD
S - Complaining of non productive cough and aggravated dyspnea since last night.
She also complains of feeling febrile since last night.
O - Patient is pale and bilateral pedal edema present
Patient appears to be in respiratory distress
- PR-99bpm
BP- 120/80mmhg
Spo2-98% at 2 litres of oxygen
RR-24cpm
Cvs -S1 S2 present
Lungs- bilateral inspiratory crackles present
Abdomen-distended with everted umbilicus
A- ckd on mhd
Type 2 diabetes since 15 years on medication
Htn since 3 years
Schizophrenic since 5 years
? Pulmonary koch’s / ? Septic emboli
P- 2D ECHO in view of any infective endocarditis changes
Sputum for cbnaat to be sent
Coagulation profile to be sent
Debate on whether to start on antitubercular therapy
Conversational Learning/CDSS -
AT- Palpable skin lesions with Cavitary lung lesions and rapidly progressive renal failure. All roads lead to Rome (GPA in this case ?)
RB- Someone still has to carve out a generous amount of lung tissue from her to prove that Rome exists? 😅
AT- In an ideal non covid world, yes sir. However, a skin biopsy with cANCA titres would be helpful here.
RB- Or can we take a short cut to Rome through her skin tissue which would be more easier? 🤔
AT- What would you expect in the skin biopsy that would take us to Rome conclusively?
AT- Necrotizing granulomatous vasuclitis. I think I saw rim enhancement of the cavity walls in the CT and also the renal lesion appears aggressively active. Some system 1 learning says cANCA in active inflammatory lesions is strongly positive and suggests a small vessel vasculitis, particularly GPA.
RB- What would be the sensitivity and specificity of this finding?
Enough to consider immunosuppresives over Sepsis treatment as both are antithetical to each other
AT - Even a renal biopsy showing pauci immune glomerulonephritis can help. Will share some system 2 data.
AT - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5059091/#!po=0.943396
Between February 1, 2005 and February 1, 2015 a total of 8403 IIF for ANCA was performed of which 1238 tested positive (27% p-ANCA, 71% c-ANCA pattern, 1% aspecific pattern) in 279 patients. A total of 5370 immunoassays for PR3 and/or MPO ANCA was performed of which 1218 samples tested positive in 239 patients (Fig.1)
RB - Can we fit our patients to any of the patients in the study you quoted here?
What are the attributes she shares with them?
AT-
- The table explains quite a lot. Patients were initially diagnosed on clinical features and then ANCA samples were sent for.
RB - Looks reassuring.
DV -https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4014960/