A sample history/case report : Myasthenia Gravis, Pyelonephrosis, Diabetes Mellitus and Hypertension

~ Aqsa Ghazanfar

Haven’t been able to post for quite some time, thought I’d share an interesting case report:

Bio data and History of Presenting Complaints:

Mrs. NA, a 47 year old married woman from Shakargarh presented to the Ittefaq hospital O.P.D on the 10th of March at around 10 am for the prescheduled removal of a catheter that had been placed in her left flank on the 23rd of February 2012 in order to drain pus from her left kidney.

History of Presenting Complaint:

Mrs. N was in her usual state of health when around 20 years ago, she developed left flank pain gradually. The pain was pressurizing in nature and mild in intensity. It did not follow any particular pattern, subsided on its own and came without warning, increasing gradually but never exceeding in severity from its usual mild character. It radiated towards the groin and the left leg, had no aggravating factors but it was sometimes alleviated by the intake of water. Along with the pain, Mrs. N also had complaints of fever which ranged from 100 to 104 degrees Fahrenheit. It was not associated with rigors or chills, there were no aggravating factors and it was relieved by taking Panadol. The fever did not follow any particular pattern and there is no associated history of altered consciousness, drowsiness or fits. The last and third associated symptom with the pain was a burning sensation while urinating. This was experienced mostly along with the fever but there is neither any history of blood in the urine nor increased frequency or urgency of urination. There were no aggravating factors and whenever the urinary symptoms appeared, Mrs. N consulted local doctors whose prescriptions usually cured her within 4-5 days. It is important to note that the episodes of pain were not always followed with fever or the urinary symptoms. Sometimes, the pain would occur on its own and sometimes it would be associated with the other two symptoms described already. The exact number of the episodes of each is not recalled by Mrs. N. The above state of health remained so until 4 years ago when the flank pain suddenly aggravated and would stay almost throughout the day, not letting her move. Its intensity increased and it radiated further down her leg and groin, even spreading into her abdomen sometimes. The associated fever would remain between 102-104 this time, not being relieved upon intake of panadol. She then consulted a doctor who prescribed her some medicines which cured her temporarily. She was told by her doctor that she had pus in her urine and her left kidney was not functioning well. She stayed on the prescribed medicine, only being cured temporarily. The pain, fever and urinary symptoms eventually started worsening over time even though she was taking her medicines. 4 months ago, the pain became absolutely unbearable. It would not go away at any time of the day and the fever would not subside, staying between 104-106 degrees Fahrenheit. She was brought to Ittefaq hospital within a day of the aggravation of her symptoms and was diagnosed to have pus in her left kidney. She was kept in the hospital for around 2 weeks but could was told that she could not be operated upon due to the fact that she was unfit for surgery because of a co-existing neuromuscular disease which deemed her unsuitable for general anesthesia. She was discharged within two weeks, only to return on the 23rd of February due to aggravation of her symptoms again. This time, a catheter was placed in her left kidney and was to be removed in 3 weeks. She went home within 2 days, but returned to Ittefaq on March 10 due to the displacement of the catheter.

Systemic Inquiry:

Mrs. N has had decreased appetite from the past 4 years. She kept gaining and losing weight from the past 4 years but has lost 11 kg in the past 1 month. She also has periorbital edema on and off and has noticed hair loss from her scalp in the past 2 years. In addition, she is generally restless and has not been able to get enough sleep from the past 4 months due to pain and the associated fever. There is no history of skin changes, swelling or ulcers. Bowel habits are all normal without any complaints of dyspnea, cough or sputum. There is no history of seizures, limb weakness, vertigo or altered consciousness. She has not experienced arthralgias, restriction of movement of her joints or any morning stiffness. There is no history of chest pain, orthopnea, etc.

Risk Factors:

Mrs. N was diagnosed with hypertension 10 years ago and diabetes mellitus 8 years ago, both of which have been controlled well with medication. She has no family history of diabetes. However, her father passed away due to complications of hypertension. There is no positive family history of diabetes mellitus or any kind of renal disorder. However, she said that she was told to have a congenital form of renal disorder, which according to her reports turned out to be a left-sided congenital pelvi-ureteric junction obstruction. There is no history of abdominal trauma, sepsis, surgery of the urinary tract and ureteric or renal stones.

Complications:

Mrs. N has had increasing flank pain associated with fever and burning during micturition but her she has never experienced any other symptoms such as blood in the urine, alteration in the frequency or urgency of urination, etc. There is no history of infection of any other organ system due to sepsis.

Past Medical & Surgical History:

Mrs. N developed difficulty in brushing her hair, getting up once she sat down on the ground, transient episodes of diplopia, difficulty in swallowing, mild respiratory distress and nasal regurgitation around 24 years ago and was diagnosed a year later to have Myesthania Gravis. She also had a surgery of the soft palate 24 years ago when her doctor thought that the nasal regurgitation could be fixed by this particular procedure. Mrs. N was diagnosed with Hypertension 10 years ago. She also experienced increased frequency and amount of bleeding during her menstrual cycle around the same time and was given medications which have she still takes and has not experienced the problem ever since. She was diagnosed with Diabetes 8 years ago which, along with the Hypertension and Myesthenia Gravis, has been under good control due to the medications she has been taking. There is no other relevant medical or surgical history.

Drug & Treatment history:

Mrs. N has been taking Deltacortil (prednisolone and prednisone 5 mg) and Bevidox (cyanocobalamin or Vitamin b12) from the past 23 years for Myesthenia Gravis, the dosage of Deltacortil being increased subsequently according to her doctor’s advice. She took Amodip (Amlodipine) 10 years ago and continued for 5 years, reverting to Aldomet (Methyldopa) 5 years ago which she is still taking for her Hypertension. She has also been taking Progyluton (Estradiol + Levonorgesterol) from the past 10 years for menorrhagia. She has been taking Metformin from the past 8 years for Diabetes Mellitus. She has been using panadol & Disprin for fever as per required, without specific advice from her doctor. She is currently being given all the above mentioned medicines along with antibiotics, analgesics and antipyretics whose exact names she does not know. A catheter that drains pus from her left kidney and exits the left flank has also been in place from February 23 till March 11. Mrs. N is not allergic to any of the aforementioned drugs and has not had any associated side effects due to their usage.

Family History:

Mrs. N’s father passed away due to complications of hypertension. Two of her siblings have heart disease. Apart from that, there is no family history of tuberculosis, diabetes, asthma or renal disorders.

Social/Personal History:

Mrs. N is a non-smoker and has never used any illicit drugs. Including her, there are 8 people in the house and her husband supports the family. They have 6 children and Mrs. N’s mother and father in law also stay with them. They belong to the lower middle class. Mrs. N is not allergic to any food, drugs or inhalants and does not recall having been vaccinated.

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