1701006133 CASE PRESENTATION

 LONG  CASE  

A 65yr old male patient who is a resident of nakrekal and farmer by occupation came to the OPD with the chief complaints of

 
Urinary retention since 2 days
Abdominal distention since 2 days
Fever since 3 days
HISTORY OF PRESENT ILLNESS:


PAST HISTORY
He had right sided indirect inguinal hernia for which hernioraphy was done 13 years back.

He is known case hypertension since 4 years and he is on medication since 4 years
No history of diabetes,asthma,tb,cad,stroke 
PERSONAL HISTORY
married
Diet:mixed
Appetite:normal
Sleep:adequate
Bowel and bladder:urinary retention
Addictions:regular alcoholic
FAMILY HISTORY:
family member has hypertension 
No history of diabetes,asthma,tb,cad,stroke.
GENERAL EXAMINATION
Patient is concious,coherent,cooperative,moderately built and moderately nourished
VITALS:
Temperature:98.7°F
Pulse rate:82b/m
Respiratory rate:22c/m
BP:140/70mmhg
Spo2:99
Grbs:134mg%

Pallor: present
Icterus:no
Clubbing:no
Cyanosis:no
Lymphadenopathy:no
Edema:present
SYSTEMIC EXAMINATION:
Shape:scaphoid
Umbilicus:central,inverted
Skin:normal
Dilated veins:no
No visible gastric peristalsis
Movements of abdominal wall:normal
PALPATION:
SUPERFICIAL PALPATION:
 No Tenderness
No local rise of temperature
DEEP PALPATION:
liver:not palpable
Spleen:not palpable
Kidney:not palpable
PERCUSSION:
Fluid thrill:absent
Liver span:14cm
AUSCULTATION:
Bowel sounds:normal
EXAMINATION OF OTHER SYSTEMS:
CARDIOVASCULAR SYSTEM:
S1,S2 Heard
 no added heart sounds
RESPIRATORY SYSTEM:
broncho vesicular breath sounds heard
CNS EXAMINATION:
Motor system and sensory system intact

Investigations













Clinical images







Provisional diagnosis: CHORNIC  KIDNEY  DISEASE 

TREATMENT: 

TAB LASIX  - 400 Mg bd

Tab nodosis-500mg bd

Inj metrogel-500mg tid

Tab pan- 40mg OD

Oroferxt- OD

Tab shelcal-od

Tab nicardipine-20mg bd

Syp arystozyme-15ml bd

                                





-------------------------------------------------------
 
SHORT  CASE 

29 YEARS OLD FEMALE WITH COMPLIANTS AND DURATION:
PIGMENTATION OVER FACE-6 MONTHS
HAIR FALL FROM SCALP- 6MONTHS
HISTORY OF LOSS OF APPETITE
HISTORY OF FEVER-6 MONTHS
HISTORY OF JOINT PAIN:6MONTHS
HISTORY OF MORNING STIFFNESS
HISTORY OF PEDAL EDEMA
HISTORY OF ULCERS IN ORAL CAVITY:5MONTHS

HOPI :
PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 15 NOVEMBER 2021.
ON 15 NOVEMBER 2021 PATIENT STARTED DEVELOPING FEVER , SWELLING AT SYNOVIUM OF ANKLE JOINT WHICH LATER LEAD TO  PEDAL EDEMA AND  ASSOCIATED WITH REDUCED PLATELET COUNT FOR WHICH SHE WAS TAKEN TO A NEARBY HOSPITAL WHERE  SHE RECEIVED THE TREATMENT AND LATER DURING THE HOSPITAL STAY SHE DEVELOPED PAIN IN ALL JOINTS ASSOCIATED WITH SWELLING AND EARLY MORNING STIFFNESS SINCE THEN. ALSO DEVELOPED PIGMENTATION OVER FACE , SCALP, BOTH EARS , NECK, BOTH HANDS AND LEGS, ARMS AND FOREARMS FOLLOWING WHICH SHE DEVELOPED ORAL ULCERS, THROAT PAIN WHICH IS ON AND OFF , THINNING OF HAIR AND HAIRFALL 

PAST HISTORY :
HISTORY OF ABORTION
 HISTORY OF SEZIURES
NO HISTORY OF DIABETES MELLITUS
NO HISTORY OF HTN
PREVIOUS SURGERIES : HYSTERECTOMY 

PERSONAL HISTORY :
DIET : MIXED
APPETITE : REDUCED
SLEEP : INADEQUATE 
BOWEL AND BLADDER : REGULAR

GENERAL EXAMINATION:
PATIENT IS C/C/C
NO PALLOR,  ICTERUS , CYANOSIS
BILATERAL PEDAL EDEMA  +













Recent photo: June month

EVENTS
VITALS :
BP - 110 / 70 mmhg
PR - 98 bpm
SPO2 - 99% @RA
TEMP - FEVER SPIKES

SYSTEMIC EXAMINATION :
CVS - S1 S2 +
RS - BAE +
CNS : NAD


INVESTIGATIONS 





ECG:
X ray findings:



PROVISIONAL DIAGNOSIS : SYSTEMIC LUPUS ERYTHEMATOSUS .


TREATMENT :
31/5/2022
PHOTO BAN CREAM (TID)
TAB CLONAZEPAM 0.5MG
2/6/2022:
TAB ULTRACET1/2 TAB OID
WYSOLONE 20MG OD
TAB HCQ 10MGBD
6/6/2022:
TAB ULTRACET 1/2 TAB OD
TAB HCQ 10MG BD
ING NEOMAL 1G I. V
TAB WYSOLONE:20 MG OD


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