LONG CASE
CHIEF COMPLAINTS
80 years old male resident of marrigudem, agriculture labourer by occupation came to OPD with the chief complaints of
i)Fever - since 3 days
ii)One episode of vomiting 2 days back
iii)Decreased urine output associated with burning micturition since - since 2 days
History of presenting illness
patient is apparently asymptomatic 3 days back.
I)He has Fever :
insidious in onset
Gradually progressive
with no diurnal variations
Relieved on medication
Associated with chills, rigors and generalised body pains. It is not associated with cough, cold, shortness of breathe, night sweats.
II)An episode of vomiting:
2 days back
Content:Food
Non bilious and not foul smelling and non projectile
III)Decreased urine output and burning micturition
Burning micturition experienced at start of the urine and relieved after the urination
Decreased urine output since 2 days no hematuria association
Past history:
He was with similar complaints in the past 10years ago, then he consulted a local doctor and relieved on medication (may be antibiotics). And there is continuation of such episodes then refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and given some diuretics as he is suffering from oliguria.
He has a recurrent episodes of fever with burning micturition later also.
He is known case of hypertension since 24years. Not a known case of diabetes, tuberculosis,asthma and epilepsy.
Surgical history
He underwent a nephrectomy surgery 27yrs ago donated to his brother.
Personal history
Appetite - normal
Diet- mixed
Sleep - adequate
Bowel - regular
Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding.
Allergies- none
Addiction- 3 beedi/ day from 27yrs of age
Alcohol- occasionally
Stopped both alcohol and smoking after the nephrectomy surgery.
General examination:
Patient is conscious, coherent, co operative and well oriented to time, place, and person
moderately build and nourished.
PALLOR
PALLOR: Present
ICTERUS:. Absent
CYANOSIS:. Absent
CLUBBING:. Absent
LYMPHADENOPATHY: Absent
PEDAL EDEMA:. Present
There was pedal edema
Gradually progressive
Pitting type
Bilateral
Below knees
No local rise of temperature and tenderness
Grade 2
Not relived on rest
Not associated with any cardiac, hepatic, venous and respiratory causes.
VITALS:
Febrile 99.2F
Bp- 150/90 mmHg ( on medication)
Pulse rate - 76 BPM
Systemic examination:
CVS examination
No visible pulsations, scars, engorged veins.
No rise in JVP
Apex beat is felt at 5 ics medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system examination
Shape of chest is elliptical, b/l symmetrical.
Trachea is central.
Expansion of chest is symmetrical
Bilateral Airway E - positive
Per abdomen examination
No visible pulsations and scars swellings.
Soft, non tender, no organo megaley.
Umbilicus is inverted.
CNS EXAMINATION:
Conscious
Speech normal
No signs of meningeal irritation
Cranial nerves: normal
Sensory system: normal
Motor system: normal
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle +. +
Gait: normal
No abdominal distension
Investigations:
Increased WBC count- 19,900
Urea - 129 mg/dl
Creatinine- 6.3 mg/dl
Urine - pus cells (plenty) - urinary tract inflammation
USG report:
1)Raised echo genicity of right kidney
2) normal size of kidney
3) mild hydronephrosis
4) not visible left kidney
Provisional Diagnosis
Acute (secondary urosepsis) on chronic kidney disease might be due to recurrent urinary tract infection.
Treatment:
Inj. Piptaz -2.25gm/tid
Tab. Lasix -40ug/po/ bd
Tab. Zofer -4mg/po/ sos
Tab. Dolo -650/ po/ sos
Tab. Pan 40mg /po/ od
Nebi. Duolin and Budecort 6hrly
Syr. Mucaine gel 15ml/po/ bd before meal 15min
Syrup. Cremaffin 15ml/po/ sos.
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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 this the patient was treated in private hospital and was tested RA POSITIVE and was 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 aspect with itching, local rise of temperature and redness.Pigmentation is seen and swelling was associated with pain which is throbbing in nature non radiating type no aggravating or releiving factors.
Dorsalis pedis artery is felt.
Erythematous rash is present on the cheek bilaterally.It is not associated with itching now. 10days 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
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.
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