1701006009 CASE PRESENTATION
LONG CASE
A 46 year old male came to casuality with chief complaints of
-burning micturition since 10days
-vomiting since 2days (3-4 episodes)
-giddiness and deviation of mouth since 1day
History of presenting illness:
Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus he was started on OHAs, 3years back OHAs were converted to insulin.
20days back he developed vomiting containing food particles, non bilious,non foul smelling(3-4 episodes),later he complained of giddiness and deviation of mouth for which he was brought to our hospital and his GRBS was recorded high value for which he was given NPH 10U and HAI 10U.
No history of fever/cough/cold
No significant history of UTIs
Past history:
10years back patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus, he was started on oral hypoglycemic agents(OHA) 10years back
3years back OHAs were converted into Insulin
3years back he underwent cataract surgery
1year back he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.
Delayed wound healing was present- it took 2months to heal
Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid
Not on any medication
No history of blood transfusion
Personal history:
Diet - Mixed
Appetite- normal
Sleep- Adequate
Bowel and bladder- Regular
Micturition- burning micturition present
Habits/Addiction:
Alcohol-
Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off consumption pattern previously present
Family history:
Not significant
Vitals @ Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
TEMP: 99F
SpO2: 98% on RA
GRBS: 124 mg/dL
General Examination:
Pallor present
No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy
No dehydration
CVS: S1S2 heard, No murmurs
RS: BAE+,NVBS
P/A: Soft, Non tender
CNS:
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs
Investigations:
On admission (19.5.22)
A 45 year old female tailor by occupation came with the cheif complaints of:
-facial rash since 4days
-fever and body pains since 3days
History of presenting illness:
Patient was apparently asymptomatic 10 years back then she developed joint pains which was associated with morning stiffness for 10mins, she was found to have Rhematoid factor positive
1 month back patient had an episode of loss of consciousness with cold peripheries with sweating.
10 days back patient developed fever and abdominal pain for which she was treated at a private hospital later she developed an erythematous rash over the face with itching, swelling of the left leg with erythema, and local rise of temperature.
Past History:
Patient had a history of diminution of vision at age of 15 years started using spectacles but there was gradual, progressive, painless loss of vision and certified as blind 2 years back .
No relevant drug, trauma history present
No similar complaints in family
Not a known case of DM/HTN/ASTHMA/CAD /EPILEPSY/TB
Personal history:
Diet- mixed
Appetite- decreased
Bowel and bladder- regular
Sleep- disturbed
Addictions- no
General examination:
Patient is conscious coherent cooperative and well-oriented with time, place, and person
moderately built and nourished
Pallor - Present
No icterus, clubbing, cyanosis, lymphadenopathy, and edema
Vitals:
Patient was afebrile
BP: 110/70 mmhg,
PR: 78bpm,
RR:18 cpm
SP02: 98%
Local examination:
Swelling at ankle associated with redness and local rise of temperature and dorsalis pedis pulses were felt.The erythematous rash was present on the face sparing the nasolabial fold.
Systemic examination:
CVS:
Inspection shows no scars on the chest, no raised JVP, no additional visible pulsations seen
all inspectory findings are confirmed
apex beat normal at 5th ics medial to mcl
no additional palpable pulsations or murmurs
percussion showed normal heart borders
auscultation S1 S2 heard no murmurs
MOTOR-: normal tone and power
reflexes: RT LT
BICEPS ++ ++
TRICEPS ++ ++
SUPINATOR ++ ++
KNEE ++ ++
SENSORY :
touch, pressure, vibration, and proprioception are normal in all limbs
GIT:
inspection- normal scaphoid abdomen with no pulsations and scars
palpation - inspectory findings are confirmed
no organomegaly, non tender and soft
percussion- normal resonant note present, liver border normal
auscultation-normal abdominal sounds heard, no bruit present
RESPIRATORY:
inspection: normal chest shape bilaterally symmetrical, mediastinum central
no scars, Rr normal, no pulsations
palpation: Insp findings are confirmed
percussion: normal resonant note present bilaterally
Investigatinons:
Hb- 6.9
TLC- 9700
Platelet count- 1.57lakhs/cumm
RBS- 130
Urea- 20
Creatinine- 1.1
Total bilirubin- 0.45
Direct bilirubin- 0.17
AST- 60
ALT- 17
Albumin- 2.18
Sodium- 136
Potassium- 3.3
Chloride- 98
Diagnosis:
Secondary sjogren syndrome
Anaemia secondary to chronic inflammatory disease with Left lower limb cellulitis
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