1701006114 CASE PRESENTATION

 LONG CASE :

A 47 year old female patient who is tailor by occupation and is resident of nalgonda came to OPD.

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 Presenting 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 blood 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. Aggravated 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, mouth ulcers

C/O decreased sweating   

Personal History:-

Diet - Mixed

Appetite - Decreased 

Sleep - Disturbed

Bowel and bladder - Regular

Addictions - nil

 

Family History:-

Younger sister had similar complaints of joint pains 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 , mile stones achieved

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) preset on face, sparing nasolabial folds. 

... Parotid Gland Enlarged.

.... Systemic Examnination:-

Respiratory System:

Inspection of Upper Respiratory Tract

Oral Cavity:-

Dental caries, Partial loss of tooth ( due to decreased saliva production)

.... Dry, Fissured tongue, Peeled Cracked Lips due to decreased saliva production

Nose; no DNS,polyp

Pharynx ; normal

Inspection of Lower respiratory tract

Position of trachea; midline

Position of Apex beat; left5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

Palpation ;

Position of trachea,apical pulse is confirmed

No tenderness over chest wall, no crepitations, no palpable added sounds, no palpable pleural rub

Percussion;

Resonant note heared, no obliteration on trabecular space

Auscultation ; 

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)

Shape; scaphoid

Umbilicus; central

Movements ; normal

No visible pulsations or engorged veins,no visible peristalsis

Skin over abdomen ;normal

Palpation; liver palpable 4cm below the costal margin with liver span of 15.5 cm,soft non tender With regular margin and smooth surface with no intercostal tenderness

* Splenomegaly, no tenderness,or local rise of temperature

Percussion ;

Liver; dullnote heared

No fluid thrills,shifting dullness

Auscultation;

Bowel sounds are heared

Cardiovascular system;

Inspection;

Position of trachea ;midline

No visible pulsations,no raised jvp

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

Palpation; no palpable thrills,parasternal heaves are palpable

Percussion ; 

Auscultation; S1,S2 heart sounds are heared , no added murmurs,

Central nervous system;

Higher mental functions : 

Level of consciousness: normal

Speech : normal

Mental state;

Memory;  normal,meningeal signs; negative

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)

Surgery

Dermatology:

Investigation:-

Previous; Complete Blood Picture

C- Peptide Serum

ECG;

Xray:

Impression, B/L minimal pleural effusion with basal lung conslidation

USG:-

Hepatomegaly with grade-2 fatty liver

B/L minimal pleural effusion with basal lung consolidation

Widal test; positive

ESR; elevated

C-reactive protein ; elevated

 ESR:-

USG:-

TSH:-

Haemogram-

CBP-

Hemoglobin:: 6gms%

RBC: 2.5million/cumm

Platelet count: 1.32lakh/cumm

PCV: 21

Peripheral smear:

Normocytic hypochromic

Relative monocytosis

Mild decrease in platelets

31/5/22

Complete blood picture;

HB: 6.9

Total leucocyte count: 9700

Platelet count: 1.57

MCV: 85.1

MCH: 27.1

MCHC; 31.8

PCV; 21.7

ESR; 90

RBS: 136

CRP: negative

Renal function tests:

Urea: 20

Creatinine: 1.1

Total bilirubin: 0.45

Direct bilirubin: 0.17

AST: 60

ALT: 17

ALP: 138

Total protein: 6.3

Albumin: 2.18

A/G; 0.53

Serology: 

HCV,HBV,HIV; negative

Sodium: 136

Potassium: 3.3

Chloride-: 98

Serum iron: 

Serum ferritin: 618.7

Complete urine examination;

Albumin: +

Sugar: nil

Pus cells: nil

RA factor: negative

Reticulocyte count: 1.7

B/G/T: AB+

24 hour urine creatinine: 0.6

24 hour urinary protein: 137

24 hour urinary volume: 1700

2/6/22

Hemogram

Hemoglobin; 7.7g/dl

Total leucocyte count: 5300cells/cumm

Neutrophil:73%

Lymphocytes-: 20%

Eosinophils: 1%

Monocytes-: 06%

Basophils: 0%

PCV; 24.6

MCV: 86fl

MCH: 26.9pg

MCHC: 31.3%

RDW-CV: 19.9

RDW-SD: 62.5

RBC count,: 2.86 million/cumm

Platelet count: 1.83 lakh/cumm

Smear;

Anisocytosis

Diagnosis;

? Secondary sjogren syndrome

Anaemia secondary to chronic inflammatory disease

with LT LL cellulitis 

B/L Optic atrophy

Treatment;

On 31/5/22;

1) inj piptaz 4.5gm iv tid

2) inj metrogyl 100ml iv tid

3) tab dolo650 mg po

4) inj neomol 1 gm iv

5) inj optineuron 1 ampoule in 100ml ns od

6) tab hifenac po bd

7) tab pan 40mg po od

8)inj nervigen 1 ampoule in 100ml ns

Cellulitis treatment:

1) tab chymoral forte tid

2) tab hifenac: bd

3) tab pan: 40mgod

4) mgso4 dressing

5) limb elevation

On 6/6/22;

1) tab deflozocart 6mg po/ BD

2) tab cefixime 200mg po/bd

3) tab orofer xt po /of

( 15 minutes before food)

4) tab rantac 150mg po/od

5) tab teczine 10mg po/ of/ha

6) hydrocortisone cream 1% /LA/ for face for 1 week

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

SHORT CASE 

50 year old male by occupation resident of Miriyalguda brought to the casualty on 8/6/22 

Chief complaints;-

 1. Shortness of breath [Grade 4] since 1 year on/off

 2. Headache to the occipital region since 20days which slowly progressed to Bilateral Parietal region along with neck pain

3. Throat pain Pricking type since 3 to 5 days

History of Presenting Illness:-

 The patient was apparently asymptomatic 1year back then he developed shortness of breath which was on off during this time period but since 20 days the patient started complaining of 

Breathlessness since 20 days which is indidious in onset Grade 3 which is associated with wheezeing and Orthopnea +, Palpitation +

and also associated with fever since 15 days low grade not associated with chills and rigors decreased on medication 

No C/o Cough, chest pain, chest tightness, haemoptysis 

Past History:-

 No Past history of TB and Covid 19

Not a Known case of Diabetes mellitus, Hypertension, Epilepsy

Family History: Insignificant

Personal History:-

Diet- Mixed

Appetite - Normal

Bowel- Regular

Bladder - Decreased Urine Output, Burning Micturation

Sleep - Adequate

Addictions- Smoking since 20 years, 1 pack daily , stopped 1 and half year

                    Inhaler Usage  since 1 and half years, daily

General Examination:-

Patient was consicous, coherent and cooperative moderate built and well nourished at the time of presentation.

No Pallor Icterus Clubbing Cyanosis Lymphadenopathy Edema

Vitals:=

Pulse- 95bpm

Blood pressure- 110/80 mmHg

Respiratory Rate- 24cpm

spO2- 96% @RA

Systemic Examination:-

Respiratory System:-

INSPECTION :

Shape of the chest : scaphoid

Symmetry : bilaterally symmetrical

Trachea : Central in position 

Expansion of the chest : Normal

Accessory muscles use for respiration : Not present 

Type of respiration : Abdomino-thoracic

No dilated veins, pulsations, scars, sinuses.

No drooping of shoulders 

No crowding of ribs 

Spino-scapular distance equal on both sides 

PALPATION :

All inspectory findings are confirmed 

No local rise of temperature 

No tenderness 

Anteroposterior diameter- 21cm

Transverse diameter-30cm 

Ratio: AP/T- 0.7

Chest expansion: 2.5 cm

PERCUSSION : 

Left- 

Direct : dull 

Indirect : dull Liver dullness for right 5th intercostal space 

Cardiac dullness within normal limits 

AUSCULTATION : 

Bilateral air entry present 

Normal vesicular breath sounds heard

CARDIOVASCULAR SYSTEM : 

 INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

PER ABDOMEN : 

INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectorial findings are confirmed.

No guarding, rigidity

Deep palpation- no Hepatomegaly or splenomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

Bowel sounds are heard.

CENTRAL NERVOUS SYSTEM : 

No focal neurological deficits

Sensory and motor systems intact 

Normal power , tone and reflexes 

INVESTIGATIONS : 

COMPLETE BLOOD PICTURE

Hemoglobin 10.1 gm/dl

Total Count 5.800 cells/cumm

Neutrophils 59%

Lymphocytes 30%

Eosinophils 01 %

Monocytes 10%

Basophils 0%

Platelet Count 2.34 lakhs/cu.mm

Smear : Normocytic normochromic 

MCHC AND PCV VALUES ARE LOWER

LIVER FUNCTION TESTS : 

Total Bilirubin 1.31 mg/dl

Direct Bilirubin 0.33 mg/dl

SGOT(AST) 26 IU/L

SGPT(ALT) 24 IU/L

Alkaline Phosphate 172 IU/L

Total Proteins 6.1 gm/dl

Albumin 3.4 gm/dl

A/g Ratio 1.25

RENAL FUNCTION TESTS : 

Urea 33 mg/dl

Creatinine 1.3 mg/dl

Uric Acid 5.7 mg/dl

Calcium 10.0 mg/dl

Phosphorous 3.1 mg/dl

Sodium 140 mEq/L

Potassium 3.6 mEq/L

Chloride 98 mEq/L

COMPLETE URINE EXAMINATIONS :

 

X RAY:

Ultrasound:-

ECG Report:-

Provisional Diagnosis;-

Shortness of Breath  secondary to COPD with gliosis and small depressed frontal bone fracture

Treatment Given;

1 MINIMAL 02 SUPPLEMENTATION @ 2 LIT

2 TAB AUGMENTIN 625 MG PO/BD

3 TAB PAN 40 MG PO/OD

4 TAB ZINCOVIT PO/OD

 

Advice at Discharge:

1 CAP FORMONIDE 200 BD X2 WEEKS

2 CAP TIOVA 9 MCG OD X 2 WEEKS

3 TAB AUGMENTN PO/BD X 3DAYS

4 TAB PAN 40 MG PO/OD X 5 DAYS