1701006087 CASE PRESENTATION

LONG 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 and  morning stiffness for about 15mins associated with limitation of movements. For this patient was treated in private hospital and was tested RA POSTIVE 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 to our hospital 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 and  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 associated 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 aggrevating 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  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 5th 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:

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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SHORT  CASE 

CASE PRESENTATION :

A 46 year old male came with chief complaints of:

Burning micturition present since 10 days

Vomiting since 2 days  ( 3 - 4 episode)

Giddiness and deviation of mouth since 1 day 

HISTORY OF PRESENTING ILLNESS:   

Patient was apparently asymptomatic 10years back, 

he complained of polyuria for which he was diagnosed

 with Type 2 diabetes mellitus he was started on OHAs.

3years back OHAs were converted to insulin.

2 days back, he developed vomiting , containing food

 particles and  non bilious. He also complained of 

deviation of mouth and giddiness 1 day

His  GRBS  was also recorded high , for which he was 

given NPH 10 IU and HAI 10 IU

No history  of fever/cough/cold

No history of previous UTIs

No history of  chest pains/palpitations/syncopal attacks

PAST HISTORY:    

    

10yrs back patient was diagnosed with Type 2 DM.

3 years back , he underwent cataract surgery.

1 year back, he had h/o small injury on leg which

 gradually progressed to non healing ulcer extending

 upto below knee eventually ended with below knee 

amputation  due to development of wet gangrene.

Not a k/c/o HTN/Epilepsy/TB/BA/Thyroid disorder/CAD/CVD

PERSONAL HISTORY:

Diet - Mixed

Appetite- normal

Sleep- Adequate 

Bowel and bladder- Regular

Micturition- burning micturition present

Habits/Addiction:

Alcohol- 

Not consuming alcohol since 1 yr.

Previously (1yr back) Consumption of 

alcohol, about 90mlwhiskey  almost daily.

Also 1month on&off  consumption pattern was 

 previously present.

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Vitals @ Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

TEMP: 101F

SpO2: 98% on RA

GRBS: 124 mg/dL

Pallor present

No Icterus/Cyanosis/Clubbing/Koilonychia/Lymphadenopathy/Edema

No dehydration

Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

P/A: Soft, Non tender

CNS: 

Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal

Power: Normal(5/5) in both Upper and Lower limbs

Tone: Normal in both Upper and Lower limbs

No meningeal signs

Investigations:

URINE  FOR KETONE BODIES 

X RAY  KUB

LFT 

RFT

Ultrasound abdomen and pelvis:

BACTERIAL CULTURE REPORT:

Culture report: Klebsiella pneumoniae positive:

Sodium- 130

Chloride- 97

Hb- 6.4

TLC- 13,700

Platelet count- 50000

Urea - 146 

Creatinine- 4.2

Uric acid- 9.1

X ray KUB 

                                                                 Dj stenting        

PROVISIONAL DIAGNOSIS:

Right emphysematous pyelonephiritis 

and left acute pyelonephiritis and encephalopathy 

secondary to sepsis.

H/o of Type 2 Diabetes mellitus since 10years

 

TREATMENT:

INJ. MEROPENEM 500mg IV BD 

INJ. ZOFER 4mg IV TID

INJ. RANTAC 50mg IV OD

INJ. LASIX 40 mg IV BD

IV Fluids- NS,RL @ 100 mL/hr

SYP. MUCAINE GEL 10 mL PO TID

INJ.HAI SC TID ACC to GRBS

TAB.DOLO 650 mg SOS