1701006082 CASE PRESENTATION
LONG CASE
A 47 year old female patient Tailor by occupation .resident of Nalgonda came to the opd on 31/5/22.
Chief complaints;
Shortness of breath since 15 days
Fever since 1 month
Generalized weakness since 2 months
Multiple joint pains since 2-3 months
History of present illness;
The patient was apparently asymptomatic 15years ago then she developed a multiple joint pains .which was insidious in onset and gradually progressive . Pain was fleeting type associated with morning stiffness .and not associated with swelling.
Pain was more over the wrist and knee.
Aggrevated on doing work and relieved by medication.( Diclofenac tablet)
* On August she had received a covid vaccine .after that she developed multiple joint pains. due to which she consulted a local doctor( orthopaedic).and recieved a medication.( Diclofenac injections for 1 week) then pain was relieved.
* On 22/11/21
She again consulted orthopaedic for polyarthritis . and some tests were done
RA factor was negative.and she was recieving medications (nsaids).
She was consulting a orthopaedic monthly twice till 14/4/22.
On 14/4/22;
She had fever which was high grade .on and off . Associated with joint pains .she consulted a local doctor.and prescribed some medications which was relieved.
On5/4/22;
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.
On 30/5/22:
She had fever which was on and off . associated with shortness of breath on exertion. And consulted a local doctor there tests were done.
Widal test ; positive
RA factor ; positive
C/O erythematous rash over face with itching . Since 1 week. Aggrevated on drug usage.
C/O swelling of left foot with redness and local rise of temperature
C/O generalized body pains
C/O loss of appetite,
C/O hair loss
C/O weight loss (72- 46 kg)
C/O caries tooth more on lower jaw
C/O dry lips, blepharitis, mouthulcers.
C/O decreased sweating.
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 .
Family history;
Her younger sister had similar complaints of joint pains .she is recieving medications since 10 years
Menstrual history;
Age of menarche; 14 years of age
28 days cycle , regular
Menopause : 1 year ago
Obstetric history;
G1 L1
Male boy,15 years old, immunized, exclusive breastfeeding for 6 months ,mole stones achieved
Personal history;
Appetite ; decreased
Diet ; mixed
Bowel and bladder; regular
Sleep; adequate
No addictions
General examination;
The patient is conscious, coherent,cooperative, moderately built and nourished.
Pallor ; present
No icterus , cyanosis,clubbing , lymphadenopathy,edema.
Vitals;
Temperature; afebrile at the time of presentation
Blood pressure; 110/70 mmHg
Heart rate; 72bpm, regular, normal volume
Respiratory rate; 14 cpm
LOCAL EXAMINATION:
Swelling was noted at left lower limb on lateral aspect of ankle which is red in color, tenderness, local rise of temperature,all pulses like anterior tibial,posterior tibial,dorsalis pedis pulses were felt
Erythematous rash, hyperpigmented present on face ,sparing nasolabial folds.
Parotid gland enlargement
Systemic examination;
Respiratory system;
Inspection of upper respiratory tract
Dental caries; partial loss of tooth ( due to decreased saliva production)
Dry ,fissured tongue, peeled cracked lips due to decreased saliva production
BAE-PRESENT
Normal vesicular breath sounds,no wheeze or no adventitious sounds
GIT;
Per abdomen;
Cranial nerves;
1 ) olfactory nerve ; percieves smell
2) optic nerve :
Visual acuity ; Right eye. ; Counting finger 1/2 Left eye; counting finger 1/2
3) occlomotor nerve ; normal
4) trochlear nerve ; normal
5) trigeminal nerve ; normal
6) abducens nerve ; normal
7) facial nerve; normal
8) vestibuli cochlear nerve; normal
9) glossopharyngeal nerve; normal
10)vagus
nerve ; normal
11) spinal accessory nerve ; normal
12) hypoglossal nerve ; normal
Gait: normal
Motor system ;
Power U/L L/L
Right 5/5 5/5
Left 5/5 5/5
Tone U/L L/L
Right normal. Normal
Left Normal Normal
Reflexes Biceps triceps supinator knee ankle
Right 2+ 2+ 2+ 2+. 2+
Left 2+ 2+. 2+. 2+. 2+
Plantar reflex: flexor
Sensory system : normal
Cerebral signs;
Finger nose in coordination; yes
Knee heel in coordination; yes
Ophthalmology ;( referral notes)
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? Secondary sjogren syndrome
Anaemia secondary to chronic inflammatory disease
with LT LL cellulitis
B/L Optic atrophy
75 year old male farmer by occupation resident of aregudem brought to the casualty on 7/6/22
Chief complaints;
Decreased responsiveness since 5 am on 7/6/22 and not able to speak
He was presented to casuality at at 10;35 am at that time his grbs was43mg/dl
History of present illness;
The patient was apparently asymptomatic 15 years back then he had fever,weakness and increased urine output then he visited local hospital and sugar test was done and diagnosed as Type 2 diabetes mellitus.and prescribed a medicine( metformin500mg+glimeperide2mg+voglibose0.2 mg).
On 7/6/22;
He was unconscious,and not able to speak since 5 am and he was presented to our hospital at 10;35 am at that time his GRBS was 43 mg/ dl.
Since last 2 days he had not taken meals and consumed alcohol
C/O excessive sweating, tremors , generalized weakness, fatigue,lethargy
C/ o decreased urine output since 2 days
C/o polyuria,polydipsia,polyphagia
No c/o blurring of vision, headache,nausea,abdominal pain,
Past history:
He had similar complaints in the past 6 years ago of decreased responsiveness due to low grbs and was treated in a local hospital with IV fluids
Not a k/c/o hypertension, coronary artery disesase,asthma, epilepsy,
Treatment history:he was on
metformin500mg+glimeperide2mg+voglibose0.2 mg). Since 15 years
Surgery : he underwent for cataract surgery for left eye 2 years ago
Family history : insignificant
Personal history;
Diet ; mixed
Appetite : normal
Bowel ; regular
Bladder: increased urine output
Sleep; adequate
Addictions: chronic alcoholic since 45 years
General examination;
Patient was unconscious at the time of presentation .
Now he was conscious, coherent, cooperative ,moderately built and nourished
Pallor : present( mild)
No icterus,cyanosis,clubbing lymphadenopathy,edema
Vitals;
Temperature: afebrile(98.6° f)
Pulse; 52bpm, regular,normal volume
Blood pressure120/80mmhg
Respiratory rate: 18cpm
Spo2 ;97% @RA
Systemic examination;
Respiratory system;
Inspection of upper respiratory tract
BAE-PRESENT
Normal vesicular breath sounds,no wheeze or no adventitious sounds
GIT;
Per abdomen;
Cranial nerves;
1 ) olfactory nerve ; percieves smell
2) optic nerve :
Visual acuity ; decreased in right eye
3) occlomotor nerve ; normal
4) trochlear nerve ; normal
5) trigeminal nerve ; normal
6) abducens nerve ; normal
7) facial nerve; normal
8) vestibuli cochlear nerve; normal
9) glossopharyngeal nerve; normal
10)vagus
nerve ; normal
11) spinal accessory nerve ; normal
12) hypoglossal nerve ; normal
Gait: normal
Motor system ;
Power U/L L/L
Right 5/5 5/5
Left 5/5 5/5
Tone U/L L/L
Right normal. Normal
Left Normal Normal
Reflexes Biceps triceps supinator knee ankle
Right 2+ 2+ 2+ 2+. 2+
Left 2+ 2+. 2+. 2+. 2+
Plantar reflex: flexor
Sensory system : normal
Cerebral signs;
Finger nose in coordination; yes
Knee heel in coordination; yes
Investigations,;
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