1701006032 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 

Chief complaints :

  

Facial puffiness and pedal Edema since 2 days 

Shortness of breath since 2 days 

Abdominal pain since 2days 

History of presenting illness :

Patient was asymptomatic 7 months back and 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 in epigastric region

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 

General examination:

Pallor: present 

Icterus: absent 

Cyanosis : absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent 

Vitals:

 Temperature: a febrile

 Pulse: 120 bpm

 Blood pressure: 150/90mmHg 

 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 is not visible 

Palpation:-

All inspiratory findings are confirmed

Trachea central in position

Apical impulse in left 6th ICS, slightly lateral

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 BREATH SOUNDS ON BOTH SIDES

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 :absent 

Skin or surface of the abdomen : normal 

PALPATION

Liver is not palpable 

PERCUSSION : Dull 

AUSCULTATION :bowel sounds heared 

INVESTIGATONS

Chest x-ray:

USG:

ECG:

PROVISIONAL DIAGNOSIS:

Chronic kidney disease on maintainance hemodialysis 

Treatment:

INJ. MONOCEF 1gm/IV/BD

INJ. METROGYL 100ml/IV/TID

INJ PAN 40mg/IV/OD

INJ. ZOFER 4mg/iv/SOS

TAB. LASIX 40mg/PO/BD

TAB. NICORANDIL 20mg/PO/TID

INJ. BUSOCOPAN /iv/stat 

Add on

TAB. OROFENPO/BD

TAB. NODOSIS 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 10days.  

   HISTORY OF PRESENT ILLNESS:

 Patient was apparently asymptomatic 10 years back then she developed joint pains started first in the knees and ankles then slowly progressed to hands associated with swelling and morning stiffness for 10 min,and for this patient went to a private hospital and found RA factor positive and treated with diclifenac and patient was asymptomatic for 8 months 

 

Last year at around month of August patient took covid vaccination of one dose following which she developed post vaccination joint pains. 

In the month of November patient consulted orthopedic and was given medication and thus relieved from symptoms. 3months back then she developed fever which was Insidious in onset Intermittent on and off not associated with chills and rigor. Relieved on medication . She went to the private hospital but the fever was recurrent associated with abdominal pain came here 5 days back.

1 month back patient had an episode of loss of consciousness associated with sweating after taking metformin tablet prescribed by local RMP 

Patient also had facial rash over the face which increased on exposure to sun. It was a diffuse erythematous lesion and hyperpigmented papules were noted over the bilateral cheek sparing nasolabial folds, following intake of unknown medication for abdominal pain

PAST HISTORY:-

Patient had an history of gradual painless loss of vision since 2011and was certified as blind 2years back

Not a known case of diabetes asthma Epilepsy thyroid tuberculosis and coronary artery disease. 

No similar complaints in the family

                                                                             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 itching pigmentation and pain which is throbbing type non radiating no aggravating and relieving factors and dorsalis pedis pulses were felt

The erythematous rash is present on the face which is not associated with the itching but was there 10days back gradually subsided

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

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.