1701006023 CASE PRESENTATION

LONG CASE 

A 51 year old patient who is a resident of chitayala ,who works is a labourer in a goods company came to the hospital with chief complaints of:

Fever since 10 days 

Shortness of breath since 10days 

Cough since 7 days 

HISTORY OF PRESENT ILLNESS :

The patient was apparently a symptomatic  10days back then he developed high grade fever which was insidious in onset associated with chills and rigours and was relieved on taking medications .

The patient was able to walk a kilometer 10 days back and later slowly was facing shortness of breath even after walking for short distances and which became so severe that even at rest he was feeling shortness of breath .Not associated with wheeze ,no Orthopnea,no paraxsomal nocturnal dyspnea ,no pedal Edema.

Cough since 7 days which is productive mucoid in consistency, whitish,scanty in amount ,non foul smelling, non blood stained .more during night time and on supine position.right sided chest pain diffuse ,

intermittent ,dragging, aggravated on cough ,non radiating ,not associated with sweating ,palpitations .

THERE is weight loss which is present ,no loss of appetite 

no history of pain abdomen abdominal distension ,vomiting ,loose stools .

no history of burning maturation .

PAST HISOTRY:

patient gives the history of jaundice 20 days back which resolved in a week without any medications .

no history of diabetes, hypertension,tuberculosis,bronchial asthma ,Copd,coronary heart disease ,thyroid disease ,cerebrovascular accident .

FAMILY HISTORY:

no similar complaints in the family 

PERSONAL HISTORY:

patient is a chronic smoker smokes a pack of cigarettes since past 25 years .

He is a chronic alcoholic consumes 325ml (quarter ml of whiskey)daily.

no bowel and bladder disturbances .

SUMMARY:

51 year old with fever cough and shortness of breath possible diagnosis

1-pleural effusion 

2-pneumonia 

3-tuberculosis 

GENERAL EXAMINATION :

patient is moderately built and nourished .

he is conscious ,comfortable .no signs of pallor ,cyanosis, icterus ,koilonychia ,lymphadenopathy ,edema .

vitals:

patient is afebrile 

pulse -83 beats per minute ,normal volume ,regular rhythm,normal character ,no radio femoral delay.

BP-110/70mmhg,measured in supine position in both arms .

Respiratory rate -22 breaths per min

SYSTEMIC EXAMINATION : 

Patient examined in sitting position

Inspection:-

oral cavity- Nicotine staining seen on teeth and gums ,nose,chest movements NORMAL

Respiratory movements appear to be decreased on right Side

Trachea is shifting towards left  & Nipples are in 4th Intercoastal space

Apex impulse visible in 5th intercostal space.

NO SIGNS OF VOLUME LOSS

no dilated veins ,scars ,sinuses ,visible pulsations ,

no rib crowding ,no accessory muscle usage .

Palpation:-

All inspiratory findings are confirmed

Trachea is shifted 

Apical impulse in left 5th ICS, 

1cm medial to mid clavicular line

Respiratory movements decreased on right side

Tactile and vocal fremitus reduced on right side in infra axillary and infra scapular region

s. 

Gastrointestinal system : 

Inspection - 

-Abdomen DISTENDED 

-All quadrants of abdomen are equally moving with respiration except Right upper quadrant 

No visibe sinuses ,scars , visible pulsations or visible peristalsis

Palpation: 

All inspectory findings are confirmed.

No tenderness .

Liver - is palpable 4 cm below the costal margin and moving with respiration.

Spleen : not palpable.

Kidneys - bimanually palpable.

Percussion - normal

Auscultation- bowel sounds heard .

No bruits .

Cardiovascular system - 

S1 and S 2 heard in all areas ,no murmurs

Final Diagnosis : 

Right sided Pleural effusion likely infectious etiology. 

INVESTIGATIONS :

XRAY:CURVED SHADOW AT THE LUNG BASE ,BLUNTIJG THE COSTOPHRENIC ANGLE AND ASCENDING TOWARDS THE AXILLA 

SHIFTING DULLNESS IS SEEN ON EXAMINATION 

Pleural fluid analysis : 

Colour - straw coloured 

Total count -2250 cells

Differential count -60% Lymphocyte ,40% Neutrophils 

No malignant cells.

Pleural fluid sugar = 128 mg/dl

Pleural fluid protein / serum protein= 5.1/7 = 0.7 

Pleural fluid LDH / serum LDH = 0.6

Interpretation: Exudative pleural effusion.

Serology negative 

Serum creatinine-0.8 mg/dl 

CUE - normal

Final diagnosis :

1.right sided pleural effusion 

2. Right lobe liver abscess 

Treatment :

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SHORT  CASE 

A 45-year-old female tailor by occupation came to the hospital on 2/6/22 with

C/O fever on and off, associated with generalized body pains, loss of appetite for 3 months 

C/O  facial rash since 4-5 days 

HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic

10 years back then she developed joint pains, the fleeting type 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 

patient was asymptomatic until 8 months back then she developed joint pains? post covid vaccination was treated at a private hospital with medications.

1 month back patient was having an episode of loss of consciousness with cold peripheries with sweating [grbs 7mg/dl] after taking Tab Glimi M2 prescribed by a local practitioner for high sugars?250mg/dl

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 was 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 :

A 45-year-old female who is conscious coherent cooperative and well-oriented with time, place, and person 

moderately built and nourished

Pallor  +

no icterus, clubbing, cyanosis, lymphadenopathy, and edema 

 

Local examination :

There is swelling in the left lower Limb on the lateral aspectWith itching, local rise pf of temperature and redness.Pigmentation is seen and swelling was associated with pain which is throbbing in nature non radiating type no aggrevating or releiving factors.

Dorsalis pedis artery is felt. 

Erythematous rash is present on the cheek bilaterally.It is not associated with itching now. 10dsys back there was itching which was gradually subsided. 

SYSTEMIC EXAMINATION;

CVS:

inspection shows no scars on the chest, no features of 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 or additional sounds

CNS: C/C/C

MOTOR-: normal tone and power 

reflexes:        RT         LT

BICEPS        ++         ++

TRICEPS     ++          ++

SUPINATOR  ++        ++

KNEE            ++         ++

SENSORY :

touch, pressure, vibration, and proprioception are normal in all limbs

sensations could not be assessed at lt ll [dressing]

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:

Haematology : hemoglobin 6g/dl 

X-rays :

Treatment:

1.INJ PIPTAZ 4.5 gm IV/ TID.

2.INJ METROGEL100 ML IV/TID

3.INJ NEOMOL1GM/IV/SOS

4.TAB CHYMORAL FORATE PO/TID

5.TAB PAN 40 MG PO/ OD.

6.TAB TECZINE10 MG PO/OD

7.TAB OROFERPO/OD.

8.TAB HIFENAC-P PO/OD

9HYDROCOTISONE cream 1%on face for 1week.

Provisional diagnosis :

SECONDARY SJOGRENS SYNDROME 

LEFT LOWER LIMB CELLULITIS WITH BILATERAL OPTIC ATROPHY