1701006181 CASE PRESENTATION

 LONG  CASE 

A 55 yr old female who is house maid by occupation came with chief complaints- 

• Head ache since 20 days
• Fever since 5 days
• Neck stiffness since 5 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 20 days back then she developed 

• headache which was  insidious onset, gradually progressive, not relieved on medications ,the headache aggravated 5 days back In spite of taking medication. No aggravating factors
• Fever which was insidious onset since,intermittent,not relieved on medication.Not associated with chills / rigors,associated with neck stiffness 
• One episode of vomiting food particles 3 days ago,non projectile, non bilious, , non blood stained.

No h/o of cold 

No h/o of cough 

No h/o of loose stools 

No h/o of abdominal pain

No h/o of breathlessness, PND , orthopnoea

No h/o of burning micturition, increased frequency of micturition. 

PAST HISTORY:

No history of similar complaints in the past.

7 yrs back she gave history of CVA due to which both upper and lower limbs were paralysed,she took medication(not specified) for  6 months and recovered.

Denovo detected diabetes

She Complaints of back pain and bilateral knee pain since 2 months

Not a known case of Hypertension,Asthma,Epilepsy,

hysterectomy done  at 25 yrs 

PERSONAL HISTORY:

• Diet: Mixed
• Appetite: Normal
• Sleep:Adequate 
• Bowel and bladder:Regular 
• No addictions 
• No known allergies

FAMILY HISTORY: Insignificant 

GENERAL EXAMINATION:

The patient was examined in a well lit room,with informed consent.

Patient is conscious,coherent,Cooperative and is moderately built and malnourished 

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent 

VITALS :

Pulse rate : 75 bpm

Respiratory rate : 15 cpm 

Blood pressure : 120/70 mm of Hg 

Temperature : afebrile

CNS EXAMINATION:

Higher mental functions:

-Patient is conscious, oriented to time and place 

-Memory is intact

-Speech and language normal

 

Cranial nerve examination:

• 2 nd cranial nerve : Visual acuity - counting fingers from 6m distance 
• 3,4,6 cranial nerves : extraocular movements present, direct indirect reflexes present. 
• 5 th cranial nerve : sensations over face present 
• 7 th cranial nerve : forehead wrinkling present, able to blow cheek, able to open and close eyes, Naso labial folds normal 
• 8 th cranial nerve : hearing normal, no Nystagmus. 
• 9, 10 th cranial nerve : uvula centrally placed and symmetrical. 
• 11 th cranial nerve : trapezius and sternocleidomastoid normal 
• 12 th cranial nerve : tongue no deviation. 

Motor examination:

                                                    

1.Bulk 

Inspection and palpation normal

Right                         Left 

   - MUAC 28 cm 27.5cm 

   - mid forearm 20 cm 20 cm

   - mid thigh 29 cm     30 cm

   - mid calf 25 cm 25 cm 

    

2.Tone 

 - upper limb normal normal 

 - Lower limb     normal normal 

3.Power 

- upper limb    5/5                       5/5 

- Lower limb 5/5                       5/5     

4.Reflexes

 - knee jerk  + +

 - Ankle jerk + +

 - Biceps + +

 - triceps + +

 - Plantar normal normal 

Meningeal signs:

1. Nuchal rigidity :  present 

2. Kernig sign :  positive 

3. Brudzinski sign :  positive  

Sensory examination:Normal

Cerebellar examination : Normal

RESPIRATORY EXAMINATION:

Bilateral air entry present 

Normal vesicular breath sounds heard 

CVS EXAMINATION:

S1 and S2 heard 

No murmurs 

ABDOMINAL EXAMINATION:

Soft, non tender abdomen 

No organomegaly 

INVESTIGATIONS:

Hemogram 

Hb - 13 g/dl

TLC - 3500

N/L/E/M-60/30/2/8

PLT- 2.1 lakh per mm3

NC/NC

Fasting blood sugar- 168 mg/ dl

Hb1 AC -6.9

Urea- 38

Serum creatinine- 1.0

Uric acid - 4.9

Sodium- 141meq

Pottasium- 4.0

chloride- 105

Arterial blood gas analysis:

PH : 7.4

PCo2 : 29.1

PO2 : 88.4

HCO3 : 18

Fasting blood sugar: 168 mg/dl  

Complete urine examination:

Albumin : positive 

Sugar : nil 

Pus cells : 6-8

Epithelial cells : 3-4

RBC and casts : nil 

Renal function test :

AST : 69 IU/L

ALT : 68 IU/L

ALP : 135 IU/L

Total protein : 6.4 gm/dl

Albumin : 4.0 gm/dl

Urea : 38 mg/dl

Creatinine : 1.0 mg/dl

Uric acid : 4.9 mg /dl

Serology : Non reactive 

INVESTIGATIONS ON 12 JUNE : 

Hemogram : 

Hb- 13.1

Tlc-16,400 /mm3 

Neutrophils- 82

Leukocytes -9

Eosinophil -1

Monocyte -8

Platelet count -1.81lakh/mm3 

Arterial blood gas analysis : 

PH - 7.44

PCO2 - 28 

PO2 - 49.3

HCO3-18.7

O2 sat - 85.1

MRI FLAIR

                                               

2D ECHO

Dengue NS1 antigen:

CSF analysis:

Sugar : 81

Protein : 12.6

Xray neck 

Xray : knee joint 

PROVISIONAL DIAGNOSIS:

Dengue fever with meningoencephalitis 

TREATMENT 

Intravenous fluids NS and RL 

Injection ceftriaxone 2 gm / ml BD 

Injection dexamethasone 6 mg intravenous TID

Injection vancomycin 1 gm intravenous sos

Injection paracetamol 1 gm intravenous SOS

Tab paracetamol 650 mg TID

Tab ecosporin 7 mg per oral OD 

Tab cremaffin 30 peroral 

Tab metformin 500 mg per oral 

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SHORT  CASE: 

A 45 year old male, who is a food contractor in railways  came to the OPD with chief complaints of:

• Shortness of breath on exertion since 2 months
• Tingling and numbness of the limbs since 2 months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2 months back then he developed then he developed shortness of breath which was insidious in onset, initially grade 2 (NYHA) then progressed to grade 3.

Patient complains of tingling and numbness of both the limbs since 2 months. Initially it was confined to lower limbs then later involved upper limbs as well. 

Patient also complains of passing dark coloured stools 3 days back.

PAST HISTORY: 

No similar complains in the past

Patient had an episode of involuntary tonic clonic movements with uprolling of eyes and drooling of saliva 20 years back. Then he went to the hospital and was diagnosed with epilepsy. He took medication , later after 15 days he experienced 2-3 episodes of seizures.

Not a known case of hypertension, diabetes mellitus,  asthma, TB

PERSONAL HISTORY:

• Diet: Mixed
• Appetite: Normal
• Sleep:Adequate 
• Bowel and bladder:Regular , passage of dark coloured stools 3 days back , one episode per day
• addictions : consumes more than quarter(whiskey) since 20 years but stopped taking alcohol since 2 months ,ghutkha chewing since 10 years
• No known allergies

FAMILY HISTORY: Insignificant 

GENERAL EXAMINATION:

The patient was examined in a well lit room,with informed consent.

Patient is conscious,coherent,Cooperative and is moderately built and malnourished 

Pallor: Present 

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent 

VITALS :

Pulse rate : 75 bpm

Respiratory rate : 15 cpm 

Blood pressure : 120/70 mm of Hg 

Temperature : afebrile

GRBS: 108 

RESPIRATORY EXAMINATION:

Bilateral air entry present 

Normal vesicular breath sounds heard 

CVS EXAMINATION:

S1 and S2 heard 

No murmurs 

ABDOMINAL EXAMINATION:

Soft, non tender abdomen 

No organomegaly 

CNS EXAMINATION:

Intact

INVESTIGATIONS

10/6/22:

CBP:

Hb : 3.2 g/dl

TLC: 3,400 cells/cumm 

Neutrophils: 42

Lymphocytes: 56

Eosinophils: 0

Monocytes: 02

Basophils: 0

PCV : 9.2

MCV: 117.9

MCH: 42

MCHC: 34.8

RDW-CV: 24.2

RBC: 0.78 

Platelets: 68,000

ESR: 40

Reticulocyte count: 0.5

LFT:

TB: 2.69

DB: 0.70

ALT: 14

AST:51

ALP: 115

TP: 5.8

Albumin: 3.6

A/G: 1.69

RFT:

Blood urea: 16

Sr. Creatinine: 0.8

Sr. Uric acid: 7.8

Sr. Electrolytes:

Sr. Calcium: 8.9

Sr. Phosphorus: 3.9

Na+: 133

Cl: 107

K+: 3.8

RBS: 104

LIPID PROFILE:

Total cholesterol: 90

Triglycerides: 116

HDL: 24

LDL: 49

VLDL: 23

12/6/22:

Hb: 2.8 g%

TLC: 2380

Neutrophils : 36

Lymphocytes: 60

Eosinophils:0

Monocytes: 4

Basophils: 0

PCV: 8

MCV: 115.8

MCH: 39.8

MCHC: 34.3

RDW-CV: 33.5

RBC: 0.69

PLT: 72,000

PS: Anisopoikilocytosis with hypochromia with microcytes, macrocytes and pencil cells. 

PROVISIONAL DIAGNOSIS:

Pancytopenia 2° to vitamin B12 deficiency

TREATMENT

INJ. VITCOFOL 1000mcg/IM/OD × 7 days

INJ. OPTINEURON 1AMP IN 100ml

TAB. PANTOP 40mg/PO/OD