1801006043 CASE PRESENTATION

LONG CASE 

A 13 year old female patient who is resident of Suryapet  came to the opd with chief complaints of shortness of breath since 3days and vomitings at night 3 days back(13-3-2023).

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 2years back she was then sent to hostel when she noticed bilateral swellings in the neck around 5 in number which where painless

She also had fever Which was insidious in onset,intermittent with evening rise of temperature which relieved with medication.

She also had cough which was dry and non productive, no hemoptysis ,relieved with medication from RMP (cough syrup).

She had all these symptoms for 2 to 3 months 

Then she 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 using ATT.

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).

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 hydroxychloroquine 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.

So they started her on ATT and recieved regular treatment for 6months.

Her symptoms settled and she was fine until January 10 when she develop generalized edema.

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 content, non bilious and non projectile.

She also developed sob grade 2 and they got her here 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,yesterday it was 25kgs.

DAily ROUTINE:

In 5th she went to hostel

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 December.

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

PAST HISTORY:

She is a known case of Tuberculosis 1year back.

Not a known case of Hypertension, diabetes mellitus, asthma, epilepsy, CAD.

TREATMENT HISTORY:

History of ATT therapy 1 year back for 6 months.

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 course was not taken completely.

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:

She is 1st born child

2nd degree consanguineous marriage

Lscs

Father has no idea about immunisation status

Menstrual history 

Not attained menarche .

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:

Temperature: afebrile 

Bp 130\80mmhg 

Pulse rate 110 bpm regular, normal volume

Respiratory rate 32 cpm

Sp02 99%.

SYSTEMIC EXAMINATION:

ABDOMINAL EXAMINATION:

Inspection:

Shape - slightly distention.

Umbilicus - Inverted

No visible pulsation,peristalsis, dilated veins and localized swellings.

Palpation:

soft, tenderness in right and left Hypochondrium, epigastrium.

Percussion:

 Shifting dullness present

Auscultation:

Bowel sounds heard

No bruit or venous hum

RESPIRATORY SYSTEM :

Bilateral air entry present

Dull not

Vocal resonance decrease.

CVS EXAMINATION:

S1 s2 heard, no murmur

JVP Raised 

CNS EXAMINATION 

No focal neurological deficits.

Higher mental functions-normal

Cranial nerves-normal

Sensory examination-normal.

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/lcc

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

X-ray chest:

Cardiac enlargement 

On usg

Liver,gallbladder,pancreas,spleen, uterus,ovaries normal

Moderate ascites

Bilateral pleural effusion

Moderate pericardial effusion

Bilateral grade 2 rpd change

Hemogram:

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

Fever chart:

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.

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SHORT CASE

A 37 year old male presented to the opd with C/O Yellowish discoluration of  eyes and passage of dark yellow coloured urine  since 1 month.

HOPI:

Patient was apparently asymptomatic one month ago he went to his village for some occassion and he had fever and cough was tested dengue positive and was also diagnosed to be ?liver failure ( Total bilirubin- 5gm/dl) also he started to notice yellowish discoloration of the sclera and dark coloured urine, 3 days later he went to a local hospital in miryalaguda where scanning was done and then his total bilirubin was 10 gm/dl for which he was given some medication and alcohol abstinance, but the patient continued drinking . He also used herbal medication for a  week as he developed itching all over the body he stopped taking the herbal medication.

He is married for 10 years, childless didn't get tested , significant alcohol history . Starting with white liquor around the age of 15-16 years it increased to cheap liquor / whisky ,daily intake of around 180 - 360 ml . H/o alcohol abstinance 2 years back for 1 year and resumed drinking last year . H/o smoking since 12 years , daily used to smoke 4 cigarettes. He stopped smoking since the last 4 years.

Past history:

Not a k/c/o DM , HTN, Asthma, epilepsy, CAD.

Personal history:

Diet - Mixed diet 

Appetite - Normal

Bowel and bladder - Regular

Sleep - adequate 

Addictions - Consumes alcohol regularly around 180- 360 ml/day.

H/o smoking since past 12yrs around 4 to 5 cigarettes/ day. He stopped smoking since the last 4 years .

Family history:

No significant family .

General examination:

Patient is conscious , coherant , cooperative .

He is oriented time, place, and person.

Moderately built and nourished.

ICTERUS-present .

There is no pallor, cyanosis , clubbing , lymphadenopathy, edema .

Vitals:

TEMP - 98.6 F

BP - 100/70 mmhg

PR - 82/ min

RR - 16 /min

SPO2 - 98 % ON RA.

Systemic examination:

CVS - S1, S2 heard, no murmurs heard. 

RS - B/L air entry present, Normal vesicular breath sounds heard.

Abdomen -

• SHAPE OF ABDOMEN - OBESE 
• ALL QUADRANTS MOVING EQUALLY WITH  RESPIRATION.
• NO SCARS AND SINUSES 
• HERNIAL ORIFICES ARE FREE.
• Mild Hepatomegaly is present
• SPLEENOMEGALY IS PRESENT
• BOWEL SOUNDS -HEARD

CNS-

• HMF - INTACT
• CRANIAL NERVES EXAMINATION - NORMAL
• SENSORY SYSTEM- INTACT
• MOTOR SYSTEM EXAMINATON - NORMAL 

CEREBELLAR EXAMINATION-

• FINGER NOSE COORDINATION - PRESENT
• KNEE HEEL COORDINATION - PRESENT 

Provisional diagnosis:

Chronic liver disease secondary to Alcohol?

Investigations:

CBP:

HB- 10.2

TLC - 7800

PLT - 1.57

LYMPHOCYTES - 12

LFT:

TB- 15.9

DB - 7.10

AST - 366

ALT - 71

ALP - 358

TP- 7.2

ALB- 3.0

A/G - 0.71

CUE 

COLOR - BROWNISH

APPERANCE - CLEAR

ALBUMIN - TRACE 

SUGARS - NIL

BILE SALTS - NIL

BILE PIGMENTS - NIL

PUS CELLS - 2-4

EPITHELIAL CELLS - 1-3

RBC - NIL

BLOOD UREA - 12 

S. CREAT- 0.5

15/11/21

LFT:

TB- 14.30

DB - 12.04

AST - 268

ALT - 56

ALP - 275

TP- 6.5

ALB- 2.62

A/G - 0.68

PT-20 sec

INR-1.4

aPTT- PROLONGED 

LFT:

TB- 13.79

DB - 12.11

AST - 201

ALT - 46

ALP - 513

TP- 6.2

ALB- 2.6

A/G - 0.73

Xray Chest pa view:

USG abdomen:

Treatment:

 -Tab. MVT /PO/OD

- syp.lactulose 15ml/PO/H/S

- inj. lorazepam 2c.c /IV/SOS

- IV Fluids (NS,RL,DNS) @50ml/hr