1701006164 CASE PRESENTATION
LONG CASE:
A 22 year old female who is farmer by occupation, presented with the complaints of
Generalised swelling of body since 5 days
Initially decreased urine output followed by no urine output since 5days
History of presenting illness
Patient was apparently asymptomatic 12 years back, then she had polyuria, polydypsia and polyphagia for which she was taken to local hospital and diagnosed with diabetes at the age of 12years and from then onwards she is on regular medication isophane insulin.
1year ago she went for the routine checkup and she was diagnosed with hypertension and she is kept on medications telma 40mg and tab nicardia 20mg .
patient presented to us on 25th may 2022 with the complaints of pedal odema, facial puffiness, decreased urine output and she underwent dialysis for 5times, antibiotics,diuretics,telma, insulin was given and discharged on 4th june 2022 with advice of salt and water restriction and protein diet is adviced.
Now patient presented on 10th june 2022 with the complaints of generalised swelling of the body since 5days initially involving face and periorbital region and later legs from ankle to thigh also upperlimb and abdomen are involved .
Swelling was insidious in onset, gradually progressive in nature no aggravating or relieving factors.
She also complains of Reduced urine output initially for 3 days followed by no urine output since 2days. No history of burning micturition.
No history of fever , abdominal pain, no history of nausea, vomiting, headache, no history of bonepain
Past History
She is a known case of diabetes and on regular insulin since 12 years, also known case of hypertension since 1year and kept on telma 40mg and nicardia 20mg .
No history of Tuberculosis, asthma, epilepsy, CVD .
Personal history
Diet - mixed diet,
appetite is reduced from 10days
Bowel and bladder - bowel is regular and decreased urine output since 5days.
Sleep - adequate
No known allergies
Family history
No history of diabetes or hypertensiom in the family members
General Examination
After taking consent , patient was examined in a well lit room after adequate exposure. She is conscious, coherent, coperative. Moderately built and nourished . Well oriented to time place and person.
On Examination she has pallor and pitting type of odema.
No icterus, cyanosis, clubbing, lymphadenopathy
vitals
Temperature - Afebrile
pulse 100bpm
Respiratory rate - 20cpm
Blood pressure - 140/90 mm Hg measured in supine position and in left upper arm
Spo2 - 97%
GRBS- 220mg/dl
Systemic Examination
Per Abdomen Examination
*Inspection :
Abdomen -distended and flanks full,
umblicus inverted and central in position .
No visible veins no scars and sinuses
*Palpation :
soft and nontender
no organomegaly,
Fluid thrill present
* percussion :
Dull note heard over the abdomen
*Auscultation :
bowel sounds +, no bruits
Respiratory system
Inspection
shape of the chest -bilateral symmetrical, movements are equal on both the sides, trachea appears to be in central in position .
Palpation - Decreased movements of chest in the both lowerlobes (infraaxillary and infra scapular)
vocal fremitus decreased in infra axillary and infrascapular area on both sides
percussion- stony dullness in infraaxillary and infrascapular area on both sides
Auscultation - Absent breath sounds on both lower lobes ISA and IAA, vocal resonance over both lower lobes.
CVS - S1 S2 heard, No murmurs
CNS - intact, Higher mental functions are normal,Motor and sensory system normal, No meningeal signs.
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 - normochromic and normocytic
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 rapid test non reactive
USG : FINDINGS
*B/l grade 2 RPD
*Gross ASCITES
*B/L MODERATE to gross PLEURAL EFFUSION.
xray
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 .
Investigations on 11/6/22.
Hemogram:
•Hb-6.2g%
•Blood urea-127 mg/dl
•Serum creatinine -6.7mg/dl
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
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SHORT CASE:
18 year old female patient who is resident of nalgonda presented with the complaints
- white lesions over both upper and lower limbs, trunk, face and right ear since 10 year
History of presenting illness
Patient was apparently asymptomatic 10 years ago then she developed white lesions over both upper and lower limbs , face ,trunk and right ear . The lesions progressively increased to the present condition
Patient gave history of usuage of unknown oral and topical medications on and off since 8 years .
No history of itching over lesion
No history of allergies
No history of chemicals application
No history of similar white lesions in the family members
Past History
No history of diabetes,hypertension, asthma, epilepsy, tuberculosis.
Personal history
Diet mixed, appetite normal, bowel and bladder regular, sleep adequate, no addictions and allergies
Family history
No similiar lesions in the family members,
no history diabetes, hypertension, tuberculosis, asthma in the family
GENERAL EXAMINATION
She is examined in a well lit room and after adequate exposure.
She is conscious, coherent, cooperative and well oriented to time ,place and person.
She is moderately built and moderately nourished.
VITALS
Temperature - Afebrile
Pulse rate - 88bpm
RR -18 CPM
BP:110/80mmhg ,measured in sitting position in left upper arm
SYSTEMIC EXAMINATION
*RS: BAE - present,no added sounds
*CVS;S1,S2 heard,no murmurs
*PER ABDOMEN:soft and non tender,No organomegaly.
*CNS: Intact
Cutaneous Examination
Multiple Depigmented macules noted over all four extremities
single white lesion on posterior trunk, scalp also over right eye and right ear.
*LEUKOTRICHIA present on lower limb macules
Provisional Diagnosis - vitiligo vulgaris
Treatment - Topical steroids - mometasone
Topical immunomodulators tacrolimus ointment
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