1701006018 CASE PRESENTATION

 LONG CASE 

A 30 year old female patient who is house wife by occupation resident of Nalgonda came to OPD with chief complaints of 

  

Facial puffiness and pedal Edema since 2 days 

Shortness of breath since 2 days. 

History of presenting illness :

Patient was asymptomatic 7 months back

She developed facial puffiness and bilateral leg swelling which was pitting in type 

SOB: insidious in onset 

          gradually progressed to grade 4 

          not associated with change in position 

          no aggravating and relieving factors 

Abdominal pain : pain since 7 days which was 

                            started suddenly and 

                            burning type of pain

Past history 

She is a known case of hypertension since 12 years 

Personal history :

Appetite : decreased 

Diet : mixed 

Sleep : inadequate 

Bladder : decreased urine output

Bowel movements: normal 

Addictions :absent 

 

Family history:

Patients mother is hypertensive since 5years

General examination:

Pallor: present 

Icterus: absent 

Cyanosis : absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent

Vitals:

 Temperature: a febrile

 Pulse: 120 bpm

 Blood pressure: 150/100 mmHg 

 Respiratory rate : 34 cpm

Systemic examination:

Respiratory system:

Patient examined in sitting position

Inspection:-

oral cavity- Normal ,nose- normal ,pharynx-normal 

Respiratory movements : bilaterally symmetrical 

Trachea is central in position & Nipples are in 4th Intercoastal space

Apex impulse visible in 6th intercostal space

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 6th ICS, 

Respiratory movements bilaterally symmetrical 

Tactile and vocal fremitus reduced on both sides  in infra axillary and infra scapular region

PERCUSSION

DULL IN BOTH SIDES

AUSCULTATION DECREASED ON BOTH SIDE in above areas

bronchial sounds are heared 

Cardiovascular system :

JVP -raised

Visible pulsations: absent 

Apical impulse : shifted downward and laterally 

Thrills -absent 

S1, S2 - heart sounds muffled 

Pericardial rub -present 

Abdomen examination:

INSPECTION

Shape : distended 

Umbilicus:normal 

Movements :normal

Visible pulsations :normal 

Skin or surface of the abdomen : normal 

PALPATION

Liver is palpable 

PERCUSSION

AUSCULTATION 

INVESTIGATONS

X-Ray:

USG:

ECG:

PROVISIONAL DIAGNOSIS:

 CKD on MHD

(Chronic kidney disease on maintainance hemodialysis)

Treatment:

INJ. MONOCEF 1gm/IV/BD

INJ. MGTILOGYL 100ml/IV/TID

INJ PAN 40mg/IV/OD

INJ. ZOFER 4mg/iv/SOS

TAB. CASIX 40mg/PO/BD

TAB. NICORANDIL 20mg/PO/TID

INJ. BUSOCOPAN /iv/stat 

Add on

TAB. ONOFER PO/BD

TAB. NODOSH 500mg/PO/TID

INJ.EPO 4000 ml/ weekly 

TAB. SHELLCAL/PO/BD 

DIALYSIS (HD)

INJ.KCL 2AMP IN 500 ml NS over 5min

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SHORT  CASE 

A 45-year-old female tailor by occupation came to the hospital with chief complaints of fever on and off, associated with generalized body pains, loss of appetite for 3 months, facial rash since 4-5 days.           

HISTORY OF PRESENT ILLNESS:  

Patient was apparently asymptomatic 10 years back then she developed joint pains associated with morning stiffness for 10 min, not associated with swelling for 2 months for which she was treated at a private hospital and found to have RA factor positive 

1 month back patient was having 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, associated swelling of the left leg with erythema, and local rise of temperature (cellulitis)

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- nil

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 malar rash

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 

Investigations:

PROVISIONAL DIAGNOSIS: 

Secondary sjogren syndrome

Anaemia secondary to chronic inflammatory disease

with LT LL cellulitis 

B/L Optic atrophy