1801006026 CASE PRESENTATION
Long case
A 30 year old female who is a resident of akkenepalli came to the medicine opd with the cheif complaints of Decreased urine output,pedal edema and facial puffiness since 5 days.
HISTORY OF PRESENT ILLNES
Patient was apparently asymptomatic 6 years then she developed generalised body ache and joint pains in the knee and elbow and ulcers in the oral cavity and hair loss with out scarring for which she went to hospital and was diagnosed with an autoimmune condition SYSTEMIC LUPUS ERYTHEMATOSIS and initiated on hydroxychloroquine, azathioprine,wysolone.
She also reported that her joint pains and her hair loss was not improving with the above medications and visited many hospitals and had multiple admissions but not subsided.
But she is continuing her medication but in November 2022 she developed shortness of breath which was sudden in onset while she is getting ready to go to her office and brought to hospital and was diagnosed as kidney failure and she had dialysis for 4 times with 3 days gap and also diagnosed as hypertensive and given antihypertensives ( nicardia 30mg) and doctor also advised to stop the drugs(hydroxychloroquine , azathioprone,wysolone)for 2 months .
After 2 months that is in February 2023 she was admitted in hospital withthe history of vomitings , diarrhea since 10 days and was diagnosed as acute kidney injury on chronic kidney failure.
Since then she is coming to hospital for dialysis once in 3 to 4 days .
Yesterday that is on 15 March 2023 she came with the complaints of pedal edema which is of pitting type since 5 days which is insidious in onset gradually progressed form ankle to knee .patient also developed puffiness around the eyes which is prominent at morning after waking up.
PAST HISTORY:
A known case of hypertension since 5 months that is in November 2022 which is secondary to kidney failure and was on regular medications .
Not a known case of diabetes ,Tuberculosis,asthma ,Epilepsy.
FAMILY HISTORY :
No such similar complaints in the family .
Only her mother has diabetes and hypertension.
PERSONAL HISTORY :
Diet:mixed
Appetite :decreased
Bowel and bladder regular .
Sleep adequate
No addictions.
DAILY ROUTINE :
Patient is a customer service executive she wakes at 7 am daily and goes to bathroom and fresh up and does bath and her mother prepare her box she goes to office daily at 8 Am and and at 10 :30 am she eats her breakfast and drinks tea and agains continues her work till 1:30 and she will have her lunch at 1:30and continues her work till 6 pm and again reaches home at 7pm and she takes bath and help her daughter in studies till 9 :30 pm and then she watch TV till 11 pm or talks to neighbors or with her mother and she goes to at 11 pm .
But Since February 2023 she is not going to her work due to regular dialysis .
MENSTRUAL HISTROY:
Age of menarche:12 years.
Menstrual cycles :Her Menstrual cycles were irregular since 2 months.
Her last Menstrual period was Dec 25th 2022.
OBSTETRIC HISTORY
Para :2, live :1(full term normal vaginal delvery)
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative. Thin built and Moderately nourished .
Vitals:Pulse rate :130 bpm
Respiratory rate :24 cycles per minute (regualr)
Blood pressure :160/100 mmhg
Temperature:Afebrile.
Patient has pallor and pedaledema which is of pitting type ,patient has flat nails,hyperpigmented discoid rashes on face,black discolouration of oral mucosa and palate.
No icterus,cyanosis ,clubbing ,lymphadenopathy.
SYSTEMIC EXAMINATION:
CVS: S1 S2 HEARD, No murmurs.
Cns:No focal neurological deficits .
Respiratory system:
Normal vesicular breath sounds,Bilateral air entry present .
Per abdomen :soft and non tender. Scaphoid shaped abdomen.
No organomegaly present .
INVESTIGATIONS:
15.03.2023
Blood urea -79 mg/dl (N=12 to 42 mg/dl)
Serum creatinine-4mg/dl(N0.6 to 1.1)
Serum electrolytes-
Na :141mEq/L(N-136 to 145)
K:3.5mEq/L(N:3.5 to 5.1)
Cl:102mEq/L(N=98 to 107)
Ionized ca+2:1.01mmol/L.
14.02.2023
HEMOGRAM:
Hb 8.5gm/dl.
Total count:12000 cell /cumm
Neutrophils:83 %
Lymphocytes:11%
Pcv:24.3 volume %
Platelets :l.lL / cumm.
Impression :Normocytic normochromic anemia with neutrophilic lymphocytes and thrombocytopenia.
Renal function test:
Urea:157mg/dl
Creatinine :6.9 mg/dl.
Uric acid :6.5 mg/dl.
ECG:
Provisional diagnosis:
Chronic renal failure secondary to lupus nephritis.
Known case of sle
Treatment:
Tab Nicradia 30mgperoral thrice a day.
Tab lasix 40mg per oral two times a day .
Tab wysolone peroral twice a day .
Tab azathioprine 50 mg per oral once daily.
Tab hydroxychloroquine 200mg peroral once daily.
Tab Met xL 25 mg per oral once daily.
Tab nodosis 500mg per oral once daily.
Tablet shelcal 500mg po od
Tab orofer xt po od
Tab Pan 40mg po od.
Tab blod3 personal weekly twice .
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short case
A 67 year old male resident of peddaoora Carpenter by occupation Came with the cheif complaints of short ness of breath since 4 years and cough since 3 years
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 4 years ago then he developed shortness of breath, insidious in onset,gradually progressive ,progressed from grade 1 to 2( MMRC) ,shortness of breath is more after smoking
no orthopnea,no PND, no pedal edema
No h/o seasonal and diurnal variations
Cough since 3years,dry cough ,more after smoking , no seasonal and diurnal variation
No h/o fever,chest pain,vomitings, Palpitations.
PAST HISTORY:
Not a known case of Diabetes mellitus ,Hypertension,Tuberculosis,Epilepsy,Asthma.
FAMILY HISTORY:
not relevant
PERSONAL HISTORY:
Diet:mixed
Appetite:decreased
Sleep :Adequate
Bowel and bladder :Regular.
Addictions:Patient is a chronic smoker since 30 years .
He used to smoke bidi 20 years back 10 bidis per day and since 10 years he is smoking cigarettes 10 per day.
DAILY ROUTINE :
He is Carpenter as well as farmer by occupation
He daily wakes at 6Am and goes to bathroom
Fresh up and baths and drinks tea at 7 am and he smokes 1 cigarette after tea and goes to agriculture field and does work there up to 10 am
And in the mean time he smokes 2 cigarettes .
And at 10 am he again comes home and have his breakfast (which may include idly ,dosa,upma etc.) And after breakfast he again smokes 1 cigarette and then goes to agriculture field works till 12 pm and in the mean time he smokes 1 cigarettes. And he reach home at
12pm and takes nap up to 1 pm and wakes at 1pm and have his lunch which consists of rice and a vegetable curry .and smokes 1 cigarette then he start doing his Carpenter work like making tabels
And ploughs (nagali) and some other stuff and works till 6pm and in the mean time he smoke
3 to 4 cigarettes and at 6 pm he stops his works and takes bath and he watch TV till 8 pm and have his dinner at 8pm smokes 1 cigarette and then sleeps at 9 pm.
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative
Moderately built and nourished.
Patient has clubbing which is of grade 2
No Pallor ,icterus,cyanosis,lymphadenopathy and edema .
Vitals:Temp:afebrile
Pulse rate :86 bpm
Respiratory rate:16 cpm Regular ,thoracoabdominal.
Bp:110/70mmHg
SYSTEMIC EXAMINATION:
Examination of Respiratory system:
INSPECTION :
Upper Respiratory tract inspection:
No Halitosis
Good oral hygiene.
oral thrush absent.
No postnasal drip .
No deviated nasal septum
No nasal polyps.
Lower Respiratory tract inspection:
Chest is symmetrical
Trachea :midline
Drooping of shoulders absent.
No intercoastal retraction
Patient have PECTUS EXCAVATUM.
No scars ,sinuses ,no dilated veins.
Movement with respiration symmetrical on both sides .
Accessory muscles are not used while respiration.
PALPATION:
All inspectory findings are confirmed.
Trachea midline.
Chest movements symmetrical on both sides .
Measurement of chest expansions: form 90 cm in inspiration to 93 cm in expiration
Tactile Vocal fremitus:All areas on Right side and left side are normal .
PERCUSSION: right left
Clavicular percussion resonant Resonant
Infraclavicular Resonant resonant
Mammary area Resonant resonant
Inframammary area Resonant Resonant
Axillary area. Resonant. Resonant
Suprascapular. Resonant. Resonant
Interscapular. Resonant. Resonant
Infrascapular. Resonant. Resonant
AUSCULTATION:
Breath sounds : Normal vesicular breathsounds .
Added sounds:crepts heard on infrascapular area.
Vocal resonance:all areas on the left and right side are resonant.
CVS EXAMINATION:
S1 S2 HEARD,NO murmurs
CNS EXAMINATION:
No focal neurological deficits.
PERABDOMEN:
Soft ,non tender
No organomegaly present .
Clinical images :
Provisional diagnosis: copd??
Chronic bronchitis??
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