1701006108 CASE PRESENTATION
LONG CASE
Chief complaints-
A 65 years old male patient, agricultural labourer by occupation came to general medicine OPD on 09-06-2022 with chief complaints of
fever - since 3 days
Urine retention since 2 days
Abdominal distension since 2 days
History of presenting illness-
patient is apparently asymptomatic 3 days back.
Then he developed fever which was
insidious in onset
gradually progressive
No diurnal variations
Relieved on medication
Associated with chills, rigors
Has generalised body pains
not associated with cough, cold, shortness of breath and night sweats
He devoloped urinary retention since 2 days.
He devoloped abdominal distension since 2 days.
Past history-
He is a known case of hypertension since 4 years.
Not a known case of diabetes mellitus, tuberculosis,asthma and epilepsy.
Surgical history-
No significant surgical history
Personal history-
.Diet- mixed
.Appetite - normal
.Sleep - adequate
.Bowel - regular
.Allergies- none
Alcohol- regularly
Family history-
No similar complaints were present in the family members.
No H/O DM,HTN.
General examination-
Patient is conscious, coherent, co operative and well oriented to time, place, and person.
moderately build and moderately nourished.
.Temperature-98.7°F
.Pulse rate-82 beats per minute
.Respiratory rate-22 cycles per mimute
.BP-140/70 mm of Hg
.GRBS-134 mg/dl
.SpO2-99% at room air
.Pallor- present
.Icterus-absent
.cyanosis- absent
.Clubbing- absent
.Lymphadenopathy- absent
.Edema- present( gradually progressive,pitting type,bilateral,grade-3 , below knee present upto ankle region from below)
Not relieved on rest
Systemic examination
CVS:
No visible pulsations, scars, engorged veins. No rise in jvp
Apex beat is felt at left 5th intercostal space medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system
Shape of chest is elliptical, biIlaterally symmetrical.
Trachea is central. Expansion of chest is symmetrical
Bilateral Airway entry - positive
Per abdomen examination:
No visible pulsations and scars,sinuses and swellings.
abdominal distension present
Soft, non tender, no organomegaley.
Umbilicus is everted
CNS EXAMINATION:
.Conscious
.Speech- normal
.Cranial nerves: normal
.Sensory system: normal
.Motor system: normal
.Reflexes- Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Provisional Diagnosis:
Chronic kidney disease on maintainance hemodialysis.
Investigations:--
Hemogram-
On 29-05-22
On 31-05-22
RFT-
On 29-5-22
On 31-5-22
LFT:-
SAAG:-
Random blood sugar-
USG report:
1)Bilateral grade -3 Renal pelvis dilation (RPD)
2) large multiple renal calculi in left kidney
3) moderate to gross ascites
Treatment:
1)Inj. Lasix 40 mg/i.v/stat
2)Tab.noclosis 500mg/po/bd
3)Tab. Orofer xj /po/od
4)Tab.shelcal 500 mg/po/od
5)Tab. Pan 40mg /po/ od
6)Tab. Nicardia 20 mg/po/bd
7)INJ. Iron sucrose 1 Amp /iv/od
8)INJ.erythropoietin 4000 U/S.C /weekly once.
Cheif Complaints:
A 45 year old female is tailor by occupation came with the cheif complaints of:
-facial rash since 4 days
-fever and body pains since 3 days
History of presenting illness:
Patient was apparently asymptomatic 10 years back then she developed joint pains which was associated with morning stiffness for 10mins, associated with limitation of movements
The she was found to have Rf +ve and was on diclofenac and remained asymptomatic for 8 months
1 month back patient had an episode of loss of consciousness with cold peripheries with sweating.
10 days back patient developed fever and abdominal pain for which she was treated at a private hospital later she developed an erythematous rash over the face with itching, swelling of the left leg with erythema, and local rise of temperature.
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 and certified as blind 2 years back .
No relevant drug history present
No similar complaints in family
Not a known case of DM/HTN/ASTHMA/CAD /EPILEPSY/TB
Personal history:
Diet- mixed
Appetite- decreased
Bowel and bladder- regular
Sleep- disturbed
Addictions- no
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 dorsalis pedis pulses were felt.The erythematous rash was present on cheek bilaterally
Systemic examination:
CVS:
Inspection:
No rise in JVP,
no additional visible pulsations seen
no scars on chest
Palpation:
all inspectory findings are confirmed
apex beat normal at 5th ics medial to mcl
no additional palpable pulsations or murmurs
Percussion: normal heart borders seen
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:
Hb- 6.9
TLC- 9700
Platelet count- 1.57lakhs/cumm
RBS- 130
Urea- 20
Creatinine- 1.1
Total bilirubin- 0.45
Direct bilirubin- 0.17
AST- 60
ALT- 17
Albumin- 2.18
Sodium- 136
Potassium- 3.3
Chloride- 98
Provisional Diagnosis:
Secondary sjogren syndrome
Anaemia with Left lower limb cellulitis
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