1701006149 CASE PRESENTATION

LONG  CASE: 

Chief complaints:

A 22 yr old female, who is a farmer by occupation, studied upto 10th standard, came to the OPD with the chief complaints of-

*Generalized swelling of the body since 5 days 

*No urine output since 5 days 

History of presenting illness:

-She was apparently asymptomatic 5 days back then she noticed swelling of the body , initially involving the face and periorbital region ,later legs from ankle to thighs and also upperlimb and abdomen.

-Swelling was insidious in onset, gradually progressive and associated with pain .no aggravating and relieving factors.

-No urine output since 5 days , initially there is decreased urine output for 2 days followed by no URINE OUTPUT.

H/o loss of appetite since 10 days 

H/o blurring of vision, for which she has been provided spectacles.(15 day ago)

No h/o burning micturition and dysuria 

No h/o fever ,rash and abdominal pain 

No h/o nausea , vomiting, headache.

No h/o chronic cough, hemoptysis and weight loss.

No h/o bone pain 

No h/o pins and needles sensation in foot 

Past history:

She is k/c/o Diabetes since 12 YEARS on regular medication (isophane insulin)

K/c/o Hypertension since 1 year on medication (tab .Telma 40 mg and tab .nicardia 20 mg)

No h/o TB, asthma, CAD, EPILEPSY, thyroid disorder.

FAMILY HISTORY:

NO h/o Hypertension, diabetes in the family members.

PERSONAL HISTORY:

Diet: mixed diet 

Appetite: decreased

Bowel and bladder: bowel is regular but bladder -no urine output since 5 days 

Sleep - adequate

GENERAL EXAMINATION:

after taking consent from patient, she is examined in a well lit room and after adequate exposure.

She is conscious, coherent, cooperative

She is moderately built and poorly nourished.

She is oriented to time, place and person

On examination she has pallor.

No  icterus, clubbing, cyanosis, lymphadenopathy

There is oedema (pitting TYPE)

VITALS:

•TEMPERATURE: febrile @time of examination

•PULSE:100 BPM

•RR:20 CPM

•BP :140/90 mm of hg , measured in supine position and in left upper arm.

•Spo2-97%

•Grbs-220 mg/dl 

SYSTEMIC EXAMINATION:

*PER ABDOMEN;

#INSPECTION;

Shape of ABDOMEN- round and distended with flank fullness 

No visible scars and sinuses

No visible engorged veins

Umbilicus is inverted and central in position.

#PALPATION;

SOFT and non tender

No organomegaly.

*Fluid thrill is present.

#Percussion;

Dull note heard over the abdomen 

#AUSCULTATION;

Bowel  sounds are heard normally

No bruit heard

*RESPIRATORY SYSTEM;

ON inspection,shape of chest is B/l symmetrical

Movements of chest -equal on both sides

Trachea appears to be in central position

On PALPATION,there is decreased movement of chest over both lower lobes ( infra axillary and infra scapular)

Vocal fremitus -decreased in IAA,ISA on both sides 

ON Percussion thers is Stony dull ness over IAA,ISA on both sides.

On AUSCULTATION; absent breath sounds over ISA,IAA .

NVBS heard above the dullness.

Vocal resonance is also decreased over both lower lobes.

*CVS;

S1,S2 heard ,no murmurs,jvp is normal.

*CNS;  intact

Higher mental functions are normal

No meaningeal signs

Motor and sensory systems are normal

Gait is normal.

PROVISIONAL DIAGNOSIS

#DIABETIC NEPHROPATHY with bilateral PLEURAL EFFUSION.

INVESTIGATIONS ON 10/6/22

#CBP:

•Hb;6.5gm/dl

•RBC count:2.42millions /cumm

•TC:7100cells/cumm

Neutrophils;70%

lymphocytes;17%

MCV:80.2fl

MCH:26.9pg

MCHC;33.5%

RDW-cv;14.2%

Platelet count:1.20lakhs/cumm 

•Smear:normocytic and normochromic

#CUE:

Color -pale yellow

Appearance-clear

Reaction -acidic

•ALBUMIN-3+

•PUS CELLS :4-5

•RBC: absent

•Casts : absent 

#BLOOD UREA:110mg/dl

#SREUM CREATININE:6.2mg/dl

#SREUM electrolytes;

Na :136mEq/l

K:3.5mEq/l

Cl:97mEq/l

#SEROLOGY;

*HbsAg; negative 

*AntiHCV antibodies;non reactive 

*HIV 1/2 rapid test ;non reactive 

#USG : FINDINGS 

*B/l grade 2 RPD 

*Gross ASCITES

*B/L MODERATE to gross PLEURAL EFFUSION.

#CHEST XRAY; 

#2DECHO; 

Investigations on 11/6/22.

Hemogram:

•Hb-6.2g%

•Blood urea-127 mg/dl

•Serum creatinine -6.7mg/dl

 Treatment;on 10/6/22

-Inj.lasix 60mg/iv/BD

-Inj .human actrapid insulin.6U/iv/stat

-Insulin infusion 6ml/hr 

-Tab.nicradia 20 mg /po/BD

-Tab .Telma 40 mg/po/OD

-NBM till further orders 

-Fluid and salt restriction

-Grbs monitoring hrly .

#Treatment on 11/6/22:

-Inj. lasix 60 mg /iv/BD 

-Inj insulin infusion 6ml/hr 

-Tab.nicardia 20 mg/po/bd

-Tab. Telma 40 mg/po/oD 

-NBM till further orders

-Fluid and salt restriction.

-Grbs monitoring hlry 

Investigations on 12/6/22

•Blood UREA:68mg/dl 

•SERUM CREATININE: 4.5mg/dl 

Treatment on 12/06/22:

-Inj.lasix 60 mg/iv/BD

-Inj human actrapid S/c 

-Tab.nicardia 20 mg /PO/BD

-Tab.Telma 40 mg/PO/OD 

-Fluid and salt restriction

-Bp/PR/Grbs 4th hourly 

-inj.piptaz 4.5mg/iv/stat

-inj.piptaz 2.5gm/iv/TID

Treatment on 13/06/22:

-Inj Piptaz 2.5gm/IV/TID

Inj Lasix 60mg/IV/BD

-Inj Human Actrapid S/C acc to GRBS

-Tab Nicardia 20 mg/BD

-Tab Telma 40mg/OD

-Tab Orofer XT PO/OD

-Tab Nodosis 500mg/BD

-Tab Shelcal 500mg/OD

- BP, pulse rate, temp 4th hourly

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SHORT  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 morning stiffness for about 15mins associated with limitation of movements. For this the patient was treated in private hospital and was tested RA POSITIVE 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 she developed fever which was Insidious in onset Intermittent on and off, not associated with chills and rigor. It was relieved on medication . She went to the private hospital but the fever was recurrent associated with abdominal pain came here 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 a 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:-

Patient is conscious coherent 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 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 aggravating  or relieving 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 5ty 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 

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