1701006197 CASE PRESENTATION
LONG CASE:
CASE DISCUSSION
A 22year old female came to the OPD with the chief complaints of
Generalised swelling over the body since 6 days.
Decreased urine output since 6 days.
Shortness of breath since 5 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6 days back and then she developed generalised swelling of the body and reduced urine output and shortness of breath.
No H/o cold, cough,fever, chest pain , orthopnea , palpitations.
PAST HISTORY
Known case of diabetes mellitus since 15 years on insulin.
Hypertension since 2years on Tab. Telma
40mg and Tab. Nicardia 20mg.
Not a known case of asthma , tuberculosis and epilepsy.
PERSONAL HISTORY
Diet - Mixed
Appetite - decreased
Bowel and bladder - decreased
No addictions
No allergies
FAMILY HISTORY
Insignificant
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative and is moderately built and nourished.
Patient is examined in a well lit room.
Pallor - present
Icterus - absent
Clubbing - absent
Cyanosis - absent
Lymphadenopathy - absent
Edema - present
VITALS
Temperature - afebrile
BP - 180/100
Pulse rate - 86bpm
Respiratory rate - 24cpm
SYSTEMIC EXAMINATION
CVS
S1,S2 sounds heard.
No murmurs
No apex beat
No palpable heart sounds
RS
Bilateral Crepitus heard.
CNS
Cranial nerves - intact
Motor system - intact
Superficial reflexes and deep reflexes are present.
No involuntary movements
Sensory system - pain , touch , temperature , vibration well appreciated.
ABDOMEN
Inspection -
Shape - distended
Flanks - full
Umbilicus - central position , inverted
No dialated veins, hernial orifice
No visible pulsations.
Palpation-
No local rise of temperature
All inspectory findings are confirmed
No guarding rigidity.
Deep palpation - no organomegaly
Percussion - fluid thrill is present
Auscultation - bowel sounds heard.
PROVISIONAL DIAGNOSIS -
Chronic kidney disease with maintenance hemodialysis .
INVESTIGATIONS
Hemogram
CLINICAL IMAGES
VIDEO ELICITING EDEMA
Ultrasound
Inj. LASIX 60mg IV/BD
Insulin infusion 6ml/hr
Injection PIPTAZ 2.25gm /TID/I
Inj. PAN IV/B
Inj. ZOFER IV/TI
Tab. NICARDIA 20 MG /B
Tab. TELMA 40 MG /O
Tab. OROFER-X5 PO/O
Tab. NODOSIS 500 MG PO/B
Tab. SHELCAL 500MG/PO/OD
Nil by mouth till further orders
Fluid and salt restriction
GRBS monitoring regularly.
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SHORT CASE:
CASE PRESENTATION
A 45 year old male came to the OPD with chief complaints of
Shortness of breath on exertion since 2 months.
Tingling sensation of limbs since 2 months.
Dark coloured stools since 3 days.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2 months back then he developed shortness of breath which is insidious in onset grade 2 gradually progressed to grade 3 .
Patient complains of tingling sensation in legs since 2 months .
Patient also complains of dark coloured stools since 3 days.
PAST HISTORY
No similar complaints in the past. Not a known case of hypertension , diabetes , asthma , epilepsy, TB.
Patient had an episode of involuntary movements with drooling of saliva and uprolling of eyeballs 20 years back and was admitted in the hospital and diagnosed as epilepsy and took medication. Later 2-3 episode of seizures were seen within 15 days. Then he had seizure free period.
PERSONAL HISTORY
Diet - Mixed
Appetite - Normal
Bowel and bladder habits - passage of dark coloured stools 3 days back , one episode per day
Addictions - Used to consume alcohol daily since 12 years about 90 ml everyday.
Alcohol abstinence since 2 months
No allergies
FAMILY HISTORY
Insignificant
GENERAL EXAMINATION
Patient is conscious, coherent and cooperative and well built and moderately nourished.
Patient is examined in a well lit room.
Pallor - present
No signs of icterus, clubbing, cyanosis, lymphadenopathy and edema.
VITALS-
Temperature- afebrile
BP- 110/80
RR- 16cpm
PR - 80bpm
SYSTEMIC EXAMINATION
CVS
S1 ,S2 heard
No murmurs
RS - NVBS heard
CNS - normal
Per abdomen
Soft , non tender
No organomegaly.
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
Serum Creatinine: 0.8
Serum Uric acid: 7.8
Serum Electrolytes:
Serum Calcium: 8.9
Serum 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
Peripheral smear - Anisopoikilocytosis with hypochromia with microcytes, macrocytes and pencil cells.
CLINICAL IMAGES
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
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