Roll no: 46
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 comeup with a diagnosis and treatment plan.
You can find the entire real patient clinical problem in this link here: (https://classworkdecjan.blogspot.com/2019/05/42-f-with-severe-regular-edema-with_17.html?m=1 )
Following is my analysis of this patients problem :
1. Frequent falls to the left with loss of function of the left side of the face and limbs. Complaint of a broken ankle after a fall from the staircase.
2. High salt intake i.e about 2 to 4 tablespoons per day.
3. Easy fatiguability with poor stress response
4. Fluctuating edema and alopecia.
And the reason for the problem may be:
1. With respect to the frequent falls to the left and loss of function and sensations of the left side of face and limbs the cause cannot be known. This may be due to raised ICP or any space occupying lesions in the brain which may give rise to migraines with cluster headache and transient balckouts.
The investigation I suggest is fundoscopy to rule out any signs of raised ICP and a lumbar puncture. MRI to rule of any space occupying lesions.
2. The patient tells us that high salt intake helps her when she is sick and she feels more salt is needed when she feels sick. There is evidence of connection between the increased salt intake with lower stress rates according to the research done at the University of haifia , department of psychology based on the study done on rats . Their blood pressure and heart rate didn't go up in response to stress and to explain their findings they theorized that aldosterone and glucocorticoids which are released act on kidney and cause dehydration also act on brain to regulate responsiveness to stressors. Thus this explains the decrease of fatiguability during sick after salt intake and the likely cause of dehydration and decreased sweating. But increased salt i.e sodium intake should cause increased blood pressure especially if potassium is not consumed in equal amount and the patient may be getting her potassium from the apple she eats everyday( 150mg of k+ in one small apple)
3. Easy fatiguability is due to hemolytic anaemia which is due to G6PD deficiency. This is already a proven fact that the patient has G6PD deficiency and AMPD1 deficiency. AMPD1 deficiency leads to decreased atp production so easy fatiguability. AMPD1 deficiency also causes decreased sleep.
4. Fluctuating edema is most commonly due to intake of foods or medications which have oxidants like menthol, fava beans etc and due to medications like anti malarials.
The patient is recommended to not consume these food items or medications.
Alopecia may be an auto immune condition.
Investigation: full genome sequencing should be done.
Treatment:
-Avoid triggers like oxidants
-If Hemolytic episode is seen then hydration +blood transfusion based on severity of anemia.
Some of the treatment options:
1.Ribose diet and keto diet
2.L serine for sleep
3.cutting oxidative stress
4.vitamin B complex
5.antioxidant vitamins
6.fructose+antioxdants
References:
-Wikipedia ( saltstick.com/2017/11/27/stress-and-salt-intake) and ( https://healthfully.com/salt-anxiety-6389233.html )
-Dr.Avinash Kumar's blog.
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