1701006045 CASE PRESENTATION

 LONG  CASE 

A 30 year old female patient, who is a housewife and resident of Nalogonda came to OPD with chief complaints of :

Puffiness in face and pedal edema since - 2 days.

Shortness of Breath since  - 2 days.

Abdominal pain since - 2 days.

History of presenting illness :

Patient was apparently asymptomatic 7 months ago.Later on  she developed facial puffiness and B/L leg swelling which was pitting in nature.

SOB: Insidious in onset , which then gradually progressed to grade 4 , not affect with change in position,  no aggravating and relieving factors .

Abdominal pain : epigastric pain 

since 7 days which started suddenly and Burning type of pain .

Past history 

She is a known case of hypertension since 12 years .

Personal history :

Diet - mixed 

Appetite - Decreased

Sleep  - Inadequate 

Bladder - Decreased urine output

Bowel movements - normal 

No addictions.

 

Family history:

Patient mother is a hypertensive .

General examination:

Pallor - present 

Icterus -  absent 

Cyanosis - absent 

Clubbing - absent 

Lymphadenopathy - absent 

Edema - absent 

Edema : absent

Vitals:

 Temperature - Afebrile

 Pulse - 110 bpm

 Blood pressure -  150/90mmHg 

 Respiratory rate - 36 cpm

# Systemic examination:

Respiratory system:

Patient examined in a sitting position.

INSPECTION:-

oral cavity- Normal

Nose- normal 

Pharynx-normal 

Respiratory movements : bilaterally symmetrical 

Trachea - central in position .

Nipples are in the  4th Intercoastal space(ICS)

Apex impulse visible in 5th intercostal space

PALPATION:-

All inspiratory findings are confirmed

Trachea - central in position

Apical impulse @  left 5th Intercoastal space.

Respiratory movements - Bilaterally(B/L) 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 sides.

bronchial sounds - heard .

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 

 Surface of the abdomen - normal 

PALPATION :

Liver - Not palpable 

PERCUSSION - Dull note is evident.

AUSCULTATION - Bowel sounds are heard .

INVESTIGATONS

USG:

Radiographic findings:

ECG:

PROVISIONAL DIAGNOSIS:

 CKD on MHD

Management :

INJ. METROGYL  @ 100ml/IV/TID

INJ. MONOCEF @  1gm/IV/BD

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 DRUGS :

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.

-------------------------------------------------------------------------------------------------------------------------------------------

SHORT CASE 

Chief Complaints:-

A 47 year old female tailor by occupation resident of nalgonda came to the OPD with the chief complaints of:

Fever since 3 months

Facial rash since 10 days

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 10 years ago then she developed joint pains first in the both knees and ankles followed by both the hands.There was swelling associated with pain morning stiffness for about 15mins associated with limitation of movements. For thus patient was treated in private hospital and was tested RA POSTIVE andwas on diclofenac,remained 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 

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 

SLEEP: Disturbed

BOWEL AND BLADDER MOVEMENTS: Regular 

ADDICTIONS: No addiction 

GENERAL EXAMINATION:-

Pateint is consious coherent co operative well oriented to time place and person,moderately built and moderately nourished and is examined with informed consent.

Pallor: present 

No icterus, cyanosis, clubbing,lymphadenopathy, edema.

VITALS:- 

PULSE :86BPM

BP:120/80mm hg

RR:16cpm

SPO2:98%at room air

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: Shape of chest in normal

no visible neck veins

No rise in JVP

No visible pulsation scars.

PALPATION: All inspectory findings are confirmed.

Cardiac impulse felt at 5ty intercostal space 1cm medial to the mid clavicular line.

PERCUSSION: shows normal heart borders

AUSCULTATION: S1 S2 heard no murmurs

CNS:-

Normal tone and power.

Sensory system : touch vibration proprioception normal.

MOTOR SYSTEM:  Normal tone and power

REFLEXES:     Right          Left

BICEPS              2+             2+ 

TRICEPS            2+             2+

SUPINATOR       2+             2+

KNEE                  2+             2+

CRANIAL NERVE EXAMINATION:- 

2nd cranial nerve      Right       Left

Visual acuity       Counting fingers positive

Direct light reflex present. Present

Indirect light reflex present. Present

Perception of light. Present. Present

Remaining cranial nerves normal.

GIT SYSTEM:-

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 SYSTEM:

INSPECTION: Shape of chest is elliptical, 

B/L symmetrical chest,

Trachea in central position,

Expansion of chest- left normal

Right - decreased 

PALPATION: All inspectory findings are confirmed,

No tenderness, No local rise of temperature,

trachea is deviated to the right,

Tactile vocal fremitus: decreased on right side ISA, InfraSA, AA, IAA.

PERCUSSION: Dull note present in right side ISA, InfraSA, AA, IAA. 

AUSCULTATION: B/L air entry present, vesicular breath sounds heard

Decreased intensity of breath sounds in right SSA,IAA

INVESTIGATIONS:-

ANA REPORT:

HEMATOLOGY:

IMPRESSION: Normocytic hypochromic ( Hb 6.0 )

Mild decrease in Platelet count 

Relative monocytosis 

Chest X-ray PA view: 

PROVISIONAL DIAGNOSIS:

SECONDARY SJOGRENS SYNDROME 

LEFT LOWER LIMB CELLULITIS WITH BILATERAL 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.