GENERAL MEDICINE CASE DISCUSSION

ANALYSING CLINICAL DATA FROM A CASE

P.VIHAR REDDY. ROLL NO-127 (8th SEMESTER)

From this case I attempt to understand the process of "patient clinical data analysis" to better myself in understanding clinical data.

The clinical case I'm looking into is of a 42 year old female patient suffering from multiple health issues.

After looking into the case details I've come to the conclusion that the patient is suffering with the following issues:-

• There seems to be an issue with her motor functioning limited to her left side.
• Her continuous migraine headaches.
• Why does such drastic swelling happen to her. (she said she could be slim in the morning and swell up by afternoon)
• Why is she sleepless, is it related to her other ailments?
• Does her being diagnosed with PCOS have any relation with her other symptoms?

1. Issue of her motor functioning lateralised to the left.

• This seems to suggest a lesion in the right side of her brain, for which we need an MRI or CT SCAN of her brain.
• The next thing that comes to mind is what caused this lesion? Since she gave no history of trauma to head before falling, we can rule out trauma.
• My next suspicion is a metabolic disorder causing hindrance with normal brain function.
• I'm suggesting this keeping in mind the other neurological symptoms she's shown like her unexplained MIGRAINE, SENSORY DISORDER and MOOD DISORDER.
• Her extreme diet habits also suggest severe nutritional deficiencies like B12, folate, etc...This is further supported by her history of having difficulty doing basic functions since an early age.
• She also has an MTFR mutation causing deficiency in folate levels which could be contributing to her neurological symptoms.
• Other causes for neurological lesion like CVA, INFECTIOUS CAUSES, are ruled out as she isn't a known hypertension case and she has no other signs indicative of infection, respectively.
• SHE ALSO HAS SLEEPLESSNESS AND VISION PROBLEMS ALONG WTIH PAINFUL SENSATIONS THESE ARE SUGGESTIVE OF FIBROMYALGIA.
• Ive considered fibromyalgia as the chances of a patient having multiple unrelated conditions is lower than having a single condition causing multiple symptoms.

TREATMENT AND INVESTIGATIONS

• For this particular issue she has we must first further investigate into where the lesion is,IF it is there and what is causing the lesion.
• So my route of action would be getting an MRI of her brain and then suggesting the necessary treatment.
• It could be something as simple as eating a healthy diet rich in all the nutrients the body needs or something as severe as a surgery.

    2. Her severe and continuous migraine headaches.

• The causes behind her migraine headaches could be a result of her lack of sleep and extreme diet habits. (causes of migraine in women)
• Migraines can have a plethora of etiologies, so id ask her to maintain a headache diary in which she'd note down every migraine headache that she faces and also notes the time when it happens and what she has done prior that day.

TREATMENT AND INVESTIGATIONS

• Firstly as mentioned above maintaining a headache diary is what i would prescribe in order to figure out the cause of her repeated migraine headaches. (way to diagnose the cause of migraine)
• In emergencies when the pain due to the headache is unbearable id prescribe TRIPTANS or an NSAID would suffice.

      3. Why does she have such drastic episodes of swelling and losing weight?

• The cause of her swelling up could be the high salt content food she eats which is causing water retention in her body.
• She also shows signs of a G6PD deficiency which can cause edema due to the unaccounted oxidative stress. (now that NADPH lvls are low)

TREATMENT AND INVESTIGATIONS

• As part of a non pharmacological approach i would suggest a low sodium diet for a period of time and observe the results.
• She should avoid certain foods and drugs (nalidixic acid, sulpha drugs) because of her  G6PD deficiency.

       4. What is the reason behind her sleeplessness?

• Considering her extreme diet and repetitive headaches her sleeplessness could be related to them.
• An unhealthy diet can cause sleeplessness.
• Theres also the possibility of fibromyalgia being the underlying cause of her sleeplessness.

TREATMENT AND INVESTIGATIONS

• I would prescribe drugs like Temazepam which will help her with her sleep.
• In case my suspicion of fibromyalgia is true id treat the underlying condition to relieve her of these symptoms.

        5. Could her PCOS be related to her other symptoms?

• Her hirsutism from a young age suggests a hormonal issue, which may have caused her PCOS and ectopic pregnancy 
• Her diagnosis of PCOS further increases my suspicion towards fibromyalgia as it has been noted that "the frequency of fibromyalgia is more in patients with PCOS." (frequency of fms in patients with PCOS)

TREATMENT AND INVESTIGATIONS

• At this point my most promising candidate for a diagnosis is fibromyalgia, but as there is no "test" for fibromyalgia we must rely solely on the group of symptoms she shows that suggest fibromyalgia.
• But there is an issue of her having no pain constantly which is one of the basic symptoms of FMS.
• Treatment involves managing the symptoms assuming FMS is the diagnosis.

I would suggest further investigations into what exactly is the underlying condition causing these myriad of symptoms.

OTHER ISSUES SHE HAS:-

• EXCESSIVE SALT DIET
• DECREASED URINE OUTPUT 
• SPONDYLOSIS OF CERVICAL SPINE 

From the various investigations performed on her we KNOW THAT SHE HAS AN SEATTLE TYPE G6PD DEFICIENCY. 

This explains most of her symptoms.

Deficiency of G6PD causes excessive hemolysis and oxidative stress on the body.

Excessive hemolysis leads to increased levels of bilirubin which in turn translates to high levels of urobilin which is toxic to the kidney, which explains repetitive kidney infections and oliguria.

The missing regulation of water and ion balance is now causing her to eat excessive salt ??