1801006024 CASE PRESENTATION

 Long Case

13 Years old female student by occupation came to casuality with

CHIEF COMPLAINTS:

Shortness of breath since Monday  (decreased now)

4 episodes of vomitings since Monday 10pm

HISTORY OF PRESENTING ILLNESS :

Patient was apparently asymptotic till the age of 11years

She was sent to hostel for studies

After few days of hostel stay she noticed that she has bilateral neck swellings 

So she was taken to RMP with complaints of neck swellings,fever and cough on and off

RMP has initiated her on ATT as her mother has also has Tb

They used ATT for 2months started in 2021 june

After initiating ATT fever increased so they stopped ATT and was referred to Hyd by the RMP

Patient was taken to hospital where she was evaluated for kochs but none of the investigations showed AFB,at that time she also had complaints of knee pains and wrist joint pains

In view of joint pains she was referred to x hospital 

In X hospital they suspected it to be autoimmune and started her on Tab Wysolone and Tab HCQ ,which she used for 15 days and stopped and later did not go there for follow up 

She was taken to another local hospital with c/o joint pains,facial puffiness,pedal edema,fever ,cough

Lymph node biopsy was done in May 2022 ?reactive(no report available but attendor was informed that it was negative for kochs)

So Mycobacterial gene expert test was done on blood sample which was also negative

But she was initiated on ATT empirically on may/2022.

10-15days before starting ATT attendors have noticed that she is developing facial rash and Hair loss,due to hair loss scalp rash also became evident.

PAST HISTORY  :

 K/C/o extra pulmonary tb (1year back used att for 6 months)

N/k/c/o hypertension, DM, epilepsy, Asthma 

BIRTH HISTORY:

1st child 

2nd degree consanguineous marriage 

Born in 2010

LSCS - delivery 

Father has no idea about immunisation status

FAMILY HISTORY :

2014 mother diagnosed with TB-expired in 2022 sept(did not use ATT regularly)

PERSONAL HISTORY:

Diet - Mixed

Appetite - Decreased appetite  

Decreased urineoutput 

Sleep - adequate 

Addictions - None

TREATMENT HISTORY :

Used Anti Tubercular therapy for 6 months for extra pulmonary tb.

GENERAL EXAMINATION : 

The patient is conscious, coherent, cooperative, and well oriented to time, place and person. 

Moderately built and Moderately nurished 

Pallor is present 

Edema of Lower Limbs is present 

No icterus, cyanosis, clubbing, lymphadenopathy 

VITALS:

,Temp: 98.4 F

PR: 126 bpm

BP: 130/90 mm Hg

RR: 26 cpm

SPO2: 98% 

SYSTEMIC EXAMINATION : 

Patient is examined in a well lit room and in a sitting position

RESPIRATORY SYSTEM:

Bilateral Air entry present

Vocal resonance is decreased in affected area 

Dull note on percussion in affected region 

C V S :

S1,S2 heard

Pericardial rub 

No murmur

PER ABDOMINAL EXAMINATION:

INSPECTION:  Shape of Abdomen - mild distended, No sinuses, fistulas. Umbillicus - Central, not everted

PALPATION: Inspectory Findings Confirmed

Soft, Tenderness present in right and left hypochondrium

Epigastrium 

PERCUSSION : Shifting dullness

AUSCULTATION: Bowel sounds Heard

C N S :

No focal neurological deficits 

HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

CRANIAL NERVES :Normal

SENSORY EXAMINATION :

Normal sensations felt in all dermatomes

MOTOR EXAMINATION :

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

REFLEXES:

Normal reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

CEREBELLAR FUNCTION :

Normal function

No meningeal signs were elicited

INVESTIGATIONS :

ECG - 

Hemogram :

 Other investigation:

 

Chest x ray - 

Clinical images  

DIAGNOSIS : 

?Autoimmune disease ? Glomerulonephritis secondary to ? Lupus

TREATMENT : 

1. FLUID RESTRICTION LESS THAN 1.5L/DAY

2. SALT RESTRICTION LESS THAN 1.2GM/DAY

3. INJ. LASIX 40 MG IV/BD

4. INJ. METHYLPREDNISOLONE 250 MG IN 100ML NS IV/OD

5. TAB. ALDACTONE 25MG PO/OD

6. TAB. SHELCAL 500 MG PO/OD

7 VITALS MONITORING

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short case

CHIEF COMPLAINTS: 

Generalised weakness since 16 days

Shortness of breath since 16 days

Easy fatigability since 16 days 

HISTORY OF PRESENTING ILLNESS:

patient was apparently asymptomatic 16 days back he developed generalised weakness insidious in onset, gradually progressive

Shortness of breath of grade 2 

Easy fatigability present

No c/o fever, nausea, vomiting, chest pain, pain abdomen, blood in stools, loose stools, sweating

1 year back, then he developed jaundice and generalised weakness for which he took herbal medicines for 10 days and was resolved. 

PAST HISTORY: 

Not a k/c/o DM/HTN/TB/ Epilepsy/CVA/CAD/Asthma

PERSONAL HISTORY:

decreased appetite since 5-6 months

Takes vegetarian diet

Bowels and bladder habits are regular

Disturbed sleep 

Occassional alcohol drinker stopped 1 year back

FAMILY HISTORY: 

No significant family history

TREATMENT HISTORY: 

No significant history

GENERAL EXAMINATION: 

patient is conscious,cohorrent cooperative 

Pallor and icterus is present

No signs of cyanosis, clubbing, lymphadenopathy, pedal edema

Vitals:

Temp: afebrile

PR: 106 bpm

RR: 20 /min

BP: 130/90 mm hg

Systemic examination:

CVS: S1 S2 heard, No Murmur 

RS: Bilateral air entry present

CNS: No focal neurological deficit 

Per Abdomen : soft, non tender, no organomegaly

Bowel sounds heard

INVESTIGATIONS :

ECG  :

CHEST X RAY :

Diagnosis: Anemia secondary to vit b12 deficiency iron deficiency (dimorphic anemia)

 Treatment: 

Inj. VITCOFOL 1000mg/IM/OD

Dermatology opinion was taken on 9/3/23 i/v/o hyperpigmented scaly lesions over abdomen, groin, inner thighs, buttocks and legs

On 10/3/23

27 year old male came with c/o generalised weakness and shortness of breath since 10 days

S 

1 fever spike 

O

Pt is c/c/c 

BP-130/70 mmhg 

PR- 92bpm

Temp- 98.5F

CVS- S1,S2 heard, no murmurs 

RS- B/L Air entry present

P/A: soft, non-tender 

CNS: HMF intact, NFND   

A

Anemia Secondary to B-12 deficiency and Iron deficiency (Dimorphic) with Tinea Corporis ET Cruris +Statis Dermatitis

 

P: 

Inj. VITCOFOL 1000mg/IM/OD

LULIFIN CREAM L/A BD

LIQUID PARAFFIN L/A BD

TAB. TECZINE 5mg SOS

 Follow up on phone call -

Normal appetite 

Recent lab report done on 14th In Nalgonda