1801006013 CASE PRESENTATION

long case

13 year old female student from suryapet came to the OPD with chief complaints of
Vomitings on Monday night
Shortness of breath since 1 day

History of present illness:
Patient was apparently asymptomatic before 2020
Then she Developed multiple swellings in the neck bilaterally,no pain, firm in consistency, 7 to 8 in number.
She also had fever insidious, intermittent, no night rise of temperature, relieved with medication dolo 3 tid
She also had cough ,dry cough, non productive, no hemoptysis ,relieved with medication from rmp (cough syrup).
She had all these symptoms for 2 to 3 months
They consulted rmp and he gave them medication probably att because her mother has tuberculosis
Swellings size decreased and symptoms were relieved.
But the fever was progressively increasing despite regular treatment so they told rmp about it and stopped it.
And rmp suggested them to go for checkup in hospital and they went to hospital in Hyderabad and got tested (fnac,cancer tests, tb tests, mantoux, sputum culture, cbnaat)because her mother is a known case of tuberculosis.
And got admitted for 10 days and recieved symptomatic treatment
(She also had complaints of joint pains wrist and knee)
They suspected it to be automimmune and started her on Hcq and wysolone tab which they used for 15 days.
ANA ELISA equivocal
ANA IFA negative
ANTI DS DNA ELISA positive
ANTI DS DNA IFA negative
She went back home
In June 2022 she started developing pigmentation/rash over face which then was seen on scalp evident because of hair loss and on trunk since 3 months,not associated with itching.
And also pedal edema upto ankles which then progressed till knee in the last 3 months,pitting type.
Then she was taken to area hospital and got tested and the attender(father) was informed that she has tuberculosis.
Ln biopsy was done
Mycobacterial gene expert test was done
No reports available
So they started her on ATT and recieved regular treatment for 6m.
Her symptoms settled and she was fine until January 10 when she develop edema again (generalized)
They went to another hospital and got tested and was told to have proteinuria.
In January and February she had mild fever and
1 week back she developed fever and edema again.
On 13 March she had episodes of vomiting 4 episodes ,food as contents,non bilious, with gap of approx 1 hr between episodes.
She also developed sob grade 2 and they got her to kmni. At 5.30 -6 am.
In 5th class her weight was 28kgs then in 6th class 23kgs,8th class 21 kgs
After att treatment her weight got improved to 23kgs that is last year
In December 26kgs, 24kgs ,yesterday it was 25kgs.

Past history
K/c/o tuberculosis
Not a known case of diabetes, hypertension, epilepsy, thyroid

Treatment history :
Used ATT for 6 months for TB

Personal history :
Single
Student
Daily routine:
She studied in local school until 4th class
In 5th she went to gurukul school and joined in hostel
And the she was fine until 6th
During 7th class she started having these symptoms
After 7th she stopped school as it got worse and she was frequently visiting hospitals.
She went to hostel again after her att treatment and subsidence of symptoms in dec.
Was fine until January and she came back home again .

In hostel previously :
5 am wake up
Gets ready by 6 am
6:30 am to the ground for yoga,exercises
7 am ragi Java
7.30 am prayer
8am classes
9.15 am breakfast
Classes until 1.30
1.30 to 2.30 lunch
2.30 to 4.30 study hour
4.30 to 5 snacks
5.00 to 6 pm walking ,playing
6 to 6.30 prayer
7 pm dinner
Till 9 pm study hour
9pm sleep

At home :
6am wake up
7 am tea
Breakfast and fruits
Tablets
Sleeps until afternoon
2.30 to 3 lunch
2 months after taking ATT her appetite was increased and she ate more food ,more frequently (5times a day).
Walking exercises
Eve 6pm fruits
Songs prayers
8pm dinner
9pm sleep

Personal history:
Diet mixed
Appetite normal
Bowel bladder movements oliguria, bowel normal
Sleep decreased
Addictions none
Family history
Mother was diagnosed with TB in 2014 and
Used ATT irregularly
She used att when she had symptoms for 1 to 2 weeks
And stopped after symptoms subside
Symptoms got worse in 2022 and she died in sept 2022

Birth history:
1st born child
2nd degree consanguineous marriage
Lscs
Father has no idea about immunisation status
Menstrual history
Not attained menarche yet

General examination:
Patient is conscious coherent and cooperative
Well oriented to time place. And person
Patient examined in well lit room

Pallor present
Icterus absent
Cyanosis absent
Clubbing absent
Lymphadenopathy absent
Edema present

Vitals
On 14\3\23
Bp 130\80mmhg
Pulse rate 110 bpm
Regular, normal volume
Respiratory rate 32 cpm
Sp02 99%

On 15\3
Bp 130/90 mm hg
Respiratory rate 26cpm
Pulse rate 120bpm
Temperature afebrile
Sp02 98%

systemic examination:
Abdominal examination
Shape - slightly distention.
Umbilicus - Inverted
Equal symmetrical movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.

Palpation
soft, tenderness in right and left Hypochondrium, epigastrium.
Percussion
Fluid thrill and shifting dullness present
Auscultation
Bowel sounds heard
No bruit or venous hum.

Respiratory examination
Bilateral air entry present
Dull note
Vocal resonance decreased

Cvs examination
S1 s2 heard, no murmurs
Pericardial rub

CNS examination
No focal neurological deficits
Higher mental functions normal
Cranial nerves normal
Sensory examination normal sensations
Motor examination normal
Reflexes normal

Investigations
Spot urine sodium 166mmol/l
Spot urinary potassium 20.5

Abg
pH 7.4
Pc02 14.9 mm hg
P02 79.8mm hg
Hc03 9.2 mmol/l
O2 saturation 96%

Serum electrolytes on 14\3
Sodium 136 meq/l
Potassium 4.4 mEq/l
Chloride 106 meq/l

Serum creatinine 0.6mg/dl
Esr 70 mm
CRP neagtive
Blood urea 29 mg\dl
FBS 100 mg\dl
Blood group 0+
Rheumatoid factor negative
HIV non reactive
Hbs ag non reactive

Urine examination:
Colour pale yellow
Appearance clear
Acidic
Specific gravity 1.010
Albumin ++
No sugar, bile salts, bile pigments, rbc, crystals, casts, amorphous deposits
Pus cells 3 to4 \hpf
Epithelial cells 2 to 3 \hpf

On usg
Liver,gallbladder,pancreas,spleen, uterus,ovaries normal
Moderate ascites
Bilateral pleural effusion
Moderate pericardial effusion
Bilateral grade 2 rpd change

Hb 7.5 g\dl
WBC 4200 cells\cumm
Neutrophils 60
Lymphocytes 36
Eosinophils 02
Monocytes 02
Basophils 0
Pcv 24.6 vol%
Mch 76.4 fl
Mchc 30.5%
Rdw 20.6 %
Rbc count 3.2 million\cumm
Platelet 1.57 laksh\cumm
Smear normocytic normochromic anemia
On 15\3
Serum creatinine 1.0 mg\dl
Sodium 1.37 meq\l
Potassium 4.7
Chloride 104
Spot urine protein 393 mg\dl
Spot urine creat 37.8 mg\dl
Ratio 10.3

On 14\3

On 15\3

Used 4 tablets per day for 6 months regularly.

Provisional diagnosis
?Automimmune disease
Glomerulonephritis secondary to lupus

Treatment
Fluid restriction
Salt restriction
Inj lasix 40mg IV BD
Inj monocef 1gm IV BD
Inj Methyl prednisolone 250mg in 100ml NS IV OD
Tab Aldactone 25mg PO OD
Tab shelcal 500mg PO OD
Vitals monitoring
-----------------------------------------------------------------------------------------------
short case

A 40 year old female patient ,hotel owner, resident of Narketpalli came with chief complaints of…
Increased heartbeat since 6 months
Breathlessness since 6 months

HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 6 months back then she developed palpitations which were sudden onset, gradually progressive and develops under stress, heavy work.
It lasts for 2 to 3 min and relives on rest .
Since the last 2 to 3 months she complains of increased frequency and intensity of palpitations.
She also complains of breathlessness ( shortness of breath) since 6 months and it was gradually progressive from grade 1 (6 months back)to 3 (presently)and it relieves on rest.
Patient also has hypoglycaemic attacks , headache when there is delay in food intake or prolonged standing and it gets relieved on taking rest or food.

PAST HISTORY
Not a known case of Diabetes, Hypertension, Asthma, Tuberculosis,Epilepsy, Thyroid disorders.
Has acidity from past 15 years.
She develops burning sensation in abdomen when she consumes oily food, spicy foods ,chapathi.
And for this she takes pantropazole every morning half n hr before food.
No history of prolonged hospital stay or surgeries.

She had sore throat 2 months back for which she consulted Local practitioner and was given some IV medication and was asked to get thyroid function test and complete blood picture done. Her thyroid profile was normal but her HB was 5.5 gm/dl.(anemic)
The local practitioner gave some oral medications for anemia but she neglected it .

TREATMENT HISTORY
Using pantop since 15 years every day morning

FAMILY HISTORY
No relevant family history

MENSTRUAL HISTORY
Menarche at 13 years
Regular cycle , 3/28
Uses 2 pads/day
Not associated with clots
No pain
Has premenstrual symptoms like back pain, leg pain

PERSONAL HISTORY

DAILY ROUTINE
She wakes up at 6.30 am
Does her morning routine
Does household work( sweeping, cleaning dishes,cooking)
Breakfast at 8.30 am
At 9 am she starts preparing items for hotel food, cleans the hotel
Lunch at 2 pm
Tea at 5pm
Dinner at 9 pm
Until then she does hotel work ( cutting vegetables, serves people, cleans hotel, cleans dishes)
Returns to home by 10 or 11 pm
Sleeps by 11 pm

Diet -vegetarian
Appetite- normal
Bowel and bladder movements-regular
Sleep-adequate
Addictions- none
Allergies -none

GENERAL EXAMINATION
Patient was conscious,coherent, cooperative
Built and nourishment- poor
Well oriented to time, place ,person
height- 5.2 inch
Weight-44 kg
BMI- 17.7

Pallor - present
Icterus- absent
Cyanosis -absent
Clubbing-absent
Lymphadenopathy -absent
Edema-absent

VITALS
Temperature -a febrile
BP- 130/90 mmHg
RR- 16cpm
PR- 84bpm

SYSTEMIC EXAMINATION

ABDOMINAL EXAMINATION
Inspection :

Abdomen flat
Moves with respiration
no abdominal distension
umbilicus is central and inverted
no engorged veins
no scars,sinuses,
hernial ornifices are clear

Palpation
   All inspectory findings are confirmed
  No tenderness

Percussion
  No significant findings

Auscultation
  Bowel sounds heard
  No bruits

RESPIRATORY EXAMINATION
Normal vesicular breath sounds
Trachea central

CARDIOVASCULAR SYSTEM
S1S2 heard
No murmurs

CENTRAL NERVOUS SYSTEM
No focal neurological deficits

INVESTIGATIONS