13 yr male with heart valve defect and renal problem

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

PATIENT HISTORY: Pt is a 13 yr old boy.

Since birth, pt. c/o of eye redness, itchy watery eyes. Taken to Vellore at age 2.5 yrs, where Dr. did a provisional diagnosis of eye allergy, and also detected ?Roth spots. MRI was recommended (not done because of financial issues). Medicines, eye drops, and specs were prescribed. No further treatment was done. Wears specs only when looking at mobile for long hr.

Pt. c/o not being able to hear clearly via rt ear and not at all via the left ear. Dr. could no any problem and recommended MRI (not done). 

Pt. even at age 2-2.5 yrs could not walk or sit. So, was taken to CMC Vellore, where Dr. recommended making pt walk with a walker. After doing therapy for 1 yr, he learned to walk at age of 3.5 yrs.

Pt's height is not increasing and is thin, and frail since birth.

Pt started talking at age of 5 yrs after many months of speech therapy. To date, pronunciation is not very clear. 

In 2019, parents noticed visible chest pulsation on a few occasions (mostly after activities).

In 2019, pt. started having 2-4 episodes of fever (102-103F, vomiting), each lasting for 2-4 days every month. The fever used to reduce with medication from a local Dr. who suspected a cardiac problem and recommended ECG and Echo. MVP was detected and pt was taken to Narayana in Nov, 2019. Sx was done and discharged on Feb 2020.

After returning home, he experienced healthy weight gain, and his appetite improved. No episodes of fever.

1 yr later, his appetite started decreasing again. Dr. said there is mild tricuspid regurgitation. Prescribed medication for 1 yr and further follow up. 

On 2022 Jan, while going for a checkup, had veg chow mien and peanuts on the train. Moments later started c/o pain in rt side of abd. His parents gave him medications thinking it to be due to indigestion. Mins later c/o high fever. Admitted to the hospital and the fever came done with medications. After doing USG Dr. suspected pyonephrosis in rt. kidney. For 7 days, given antibiotics b.d. Recommended to do MCU test but not done because of financial issues.

In the past 1 yr, only one incident of pain in abd (reduced with medication)

On Dec 2022, 1 incident of high fever lasted for 3 days.  

Pt. had never c/o SOB or chest pain and only reported a few occasions of palpitation.

Maintains an active lifestyle

CHIEF COMPLAINT AND PT. REQ.: 1) Heart valve repair done, seeks further consultation

2) Pain in rt side of abd, 3 incidents till date, seeks consultation

3) Growth deficit, decreased appetite, hearing issues, can't pronounce words clearly

4) Eye checkup

FAMILY HISTORY: Father - denied any health issues, and needed counseling because of depression due to his son's sufferings and financial problems.

Mother - denied any health issue

Denied any family history of similar complaints

DAILY ROUTINE AND DIET:

Breakfast - milk with horlicks, biscuits

Lunch - rice, dal, sabji

Evening - milk, soup, veg noodles

Dinner - rice, roti, khichdi

Most of the day is spent outside playing with friends, apart from watching TV or playing mobile games.

REPORTS:

CURRENT MEDICATION: Lasilactone 50mg (Furosemide and Spironolactone) half tab. o.d, Envas 2.5mg (Enalapril) half tab o.d, Ecosprin o.d, Bactrim ds (sulfamethoxazole and trimethoprim) o.d

PROVISIONAL DIAGNOSIS: severe MR, mild TR, pyonephrosis