1701006003 CASE PRESENTATION
LONG CASE
26 year old female who is a resident of nalgonda and housewife came with the complaints of
▪ Lower back ache since 15 days
▪ Fever since 10 days
HISTORY OF PRESENTING ILLNESS
▪Patient was apparent asymptomatic 15 days back then she developed severe lower back adhe which was insidious in onset and gradually progressive and continuous type which was squeezing in character and not a radiating type of pain and it gets relieved by medication and the injection given by local doctor there are no associated symptoms
▪ Then she developed fever 10 days back which was insidious in onset which started as chills then developed fever which was gradually progressive and associated with chills and rigors more during night times
▪ She had vomitings on 2nd( 1 episode) and 3rd June ( 5 to 6 episodes) with food as content and non bilious and not projectile and there are no associated symptoms such as abdominal pain and got relieved with medication given on 4th june
▪ She had noticed red coloured urine on 1st and 2nd june not associated with pain or difficulty in passing urine, no oliguria or increased frequency of urination, no urge to pass urine, there is a feeling of incomplete voiding of urkne
▪ she had puffiness of face and abdominal distension on 6th june and got subsided
▪ There is no history of chest pain , difficulty in breathing, cough, indigestion or heart burn, pain or stiffness or swelling in the joints
PAST HISTORY
▪ no similar complaints in the past
▪Patient had history of chest pain when she was 10 years old diagnosed rheumatic heart disease for which she was on medication for it but no subsided so surgery was done( CABG , MITRAL VALVE REPLACEMENT) then she was on prophylaxis for 2 years then she discounted then she had c section done 7 months back as baby is weak she consulted doctor from then she again started the penicillin prophylaxis
▪ She has a history of PCOS for which she is on medication
▪ not a known case of diabetes, Hypertension, asthma, tuberculosis
MARITAL HISTORY
3rd degree consangious marriage , 6 years back and had 7 months old baby
FAMILY HISTORY
not significant
PERSONAL HISTORY
Diet - mixed
Appetite- normal
Sleep - decreased because of pain
Bowel and bladder movements - regular
no addictions
no allergies
MENSTRUAL HISTORY
menarche - 13 years
regular periods
5/ 28 - moderate flow
not associated with pains
GENERAL EXAMINATION
Patient is conscious coherent cooperative well oriented to time , place , person moderately built and moderately nourished
Pallor- present
Icterus- absent
Cyanosis- absent
Clubbing - absent
Lymphadenopathy - absent
Edema- absent
VITALS
Pulse- 70 bpm
Respiratory rate- 34 per min
Blood pressure- 120/ 70 mm hg
Temperature - afebrile
SYSTEMIC EXAMINATION
Per abdomen
INSPECTION
shape of abdomen- normal
c section scar is seen and stria gravidarum
no abdominal swellings seen
no dilated veins are seen
no visible peristalsis
all quadrants are moving equally with respiration
PALPATION
No local rise of temperature and no tenderness
no palpable mass
no hepatomegaly and no spleenomegaly
Kidney - ballatoble
PERCUSSION
resonant sound heard
ASCULTATION
Bowel sounds heard
CVS
INSPECTION
midline scar is seen
shape of chest - normal
no precordial bulge seen
JVP not raised
no visible pulsations
PALPATION-
Apex beat felt at left 5th intercoastal space 2.5 cms lateral to mid clavicularl ine
Ausculatation -
S1 , S2 heards
no murmurs
click sound heard ( without stethescope)
Respiratory system- normal
CNS- intact
INVESTIGATIONS
on day 1
Hemoglobin- 9.8
Total leukocyte count- 21900
neutrophils- 83
lymphocyte- 07
basophils- 02
monocytes- 08
Platelets- 2.1 lakh
Normocytic mormochromic anemia
LIVER FUNCTION TEST
Appt- 51secs
Pt -25 secs
INR- 1.8
Random blood sugar- 101 mg/ dl
Urea- 26
Electrolytes
Serum creatinine- 1.4
Sodium- 141meq
Pottasium- 3.4
chloride- 106
day 4th
Hemoglobin- 10.1
Urea- 18
NCCT
50 year old male with
▪weakness of both lower limbs
and slurring of speech since 5 days
HISTORY OF PRESENTING ILLNESS
Patient had a history of fall 1 year ago and he did not take any treatment for it and was alright for 8 months then 4 months back he had pain in right hip which was insidious in onset and gradually progressive in nature
since 1month there was change in the gait of patient which was noticed by his relatives and there is hematuria for 5 days which he has neglected
For which he consulted local doctor and diagnosed avascular necrosis of of femur for which he has given medication
After taking medication he developed weakness of both lower limbs but more on right side where he could not walk , stand and eat and he need assistance for these activities
PAST HISTORY
Known case of diabetes since 12 years and takes insulin daily 2 times ( 15 U before breakfast, 10 U in the evening)
not a known case of hypertension, asthma , TB, epilepsy
PERSONAL HISTORY
Diet- mixed
Appetite- normal
Sleep - Adequate
Bowel and bladder movements- regular
Addiction- smoker since 12 years takes 1 beedi per day and stopped for 4 years and again started smoking from 1 year
consumed alcohol nearly for 20 years and stopped taking it
FAMILY HISTORY
Insignificant
GENERAL EXAMINATION
Patient is conscious coherent cooperative, well oriented to time place person
Moderately built and moderately nourished
Pallor- mild
icterus- absent
cyanosis- absent
clubbing- absent
Lymphadenopathy - absent
Edema- present
On 02/06/2022:
Bp - 120/80mmhg
PR - 92bpm
RR -17cpm
SpO2 -97%
GRBS - 150mg/dl
systemic examination
▪CVS-- s1 ,s2 heard no murmurs
• Respiratory system- normal vesicular breath sounds heard
• Abdomen- no tenderness no. . palpable mass , not distended
c/c/c and afebrile
CVS - S1 S2+
CNS - Sensorium improved
P/A - soft and non tender
On 04/06/2022:
c/c/c and afebrile
BP - 120/80mmhg
PR - 88bpm
CVS - S1 S2+
CNS - Sensorium improved
On 05/06/2022:
c/c/c
BP - 100/60mmhg
PR - 92bpm
CVS - S1 S2+
CNS - Sensorium improved
R/S - BAE + and LT CREPTS +
P/A - soft and non tender.
On 07/06/2022:
BP - 120/80mmhg
PR - 92bpm
Atrophy of right calf region
sensations of both limbs - intact
absence of mobility of both limbs
Provisional Diagnosis:
Hypokalemic periodic paralysis
INVESTIGATIONS
29/5 /2022
Rt kidney - 8.8 * 4.2 cm
Lt kidney - 10*3.6 cm
Size is normal but increased echotexture
CMD - partially maintained
Spleen - 12.9cm (increased)
Multiple intraductal and parenchymal calcification noted in pancreas involving and head and pancreas.
8mm calculus noted in inferior pole of left kidney.
Distended gall bladder with calcification noted of 6mm.
IMPRESSIONS ON USG
• Cholelithiasis with GB sludge
• chronic pancretitis
• left renal calculus
• mild
splenomegaly
• B/L grade - II RPD changes
• minimal ascitis
4/06/2022
5/06/2022
ECG Reports:
On 02/06/2022
On 06/06/2022:
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