1801006052 CASE PRESENTATION

 A 13 year old female patient resident of    Suryapet presented to OPD with 

CHIEF COMPLAINTS

Vomitings  since 1 day  

Shortness of breath since 1 day

HISTORY OF PRESENTATION 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 bilateral swellings  over the neck 5-6 in number 

History of fever which is insidious in onset,intermittent, not associated with chills and rigors no evening rise of temperature 

History of cough which is intermittent and not associated with any sputum 

 for which she was taken to RMP, he  has initiated her on ATT as her mother has also has Tuberculosis 

They used ATT for 2months started in the month of June 2021

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

Patient was taken to hospital where she was evaluated for tuberculosis  but was tested as negative for Acid fast bacilli, culture,cbnaat. ,she also  complained  of  bilateral knee and wrist joint pains.

In hospital they suspected it to be autoimmune and started her on Tab Wysolone and Tab HCQ ,which she used for 15 days and stopped.

Patient was tested for -

ANA ELISA-equivocal,ANA IFA-negative

Anti Ds DNA ELISA-Positive,Anti Ds DNA IFA negative.

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

Lymph node biopsy was done in the month of May 2022

Mycobacterial gene expert test was done and was confirmed with Tuberculosis and was started on ATT for 6 Months.

 Before starting ATT attendors had noticed that she is developing facial rash  ( black in colour)  rash all over the body and Hair loss.

Patient was fine till the month of January 2023 ,she developed generalised edema due to proteinuria. 

Fever was on and off from then which got  relieved on taking medication.

Pedal edema  since 2 weeks  till the level of knee, Abdominal distension since 1 week .

March 13: She had Vomitings 4 -5 episodes non  bilious ,food as content.

Shortness of breath of grade 2 

PAST HISTORY:

Patient is a known case of Tuberculosis, diabetes, Hypertension, epilepsy,asthma.

PERSONAL HISTORY:

Daily routine - Patient wakes up at 7 am does her daily routine work , previousy she used to stay at hostel ,goes to school at 9 am ,lunch at 1 pm ,comes back from school  take some snack ,playtime till 6 pm, dinner at 7 :30 pm and goes to sleep at 10 pm .

Now patient wakes up at 7 am does her routine work,take break fast at 9 am and takes rest lunch at 1 pm ,snacks ,fruits at 4:30 ,8 pm dinner,9 pm sleep.

Appetite - decreased.

Diet - Mixed

Bowel and bladder movements: patient complained of decreased urine output,bowel movements are normal .

Sleep: inadequate 

FAMILY HISTORY:

Mother is a known case of Tuberculosis ,died 6 months ago 

BIRTH HISTORY: She is the first child born out of 2nd degree consanguineous marriage

MENSTRUAL HISTORY

Not attained menarche .

GENERAL EXAMINATION:

Patient is conscious coherent and cooperative ,well oriented to time place and person poorly built and moderately nourished 

Pallor present

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Bilateral pedal edema present

Vitals:

Temperature

 Pulse rate:

Blood pressure:

Respiratory rate:

SYSYTEMIC 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

Respiratory examination:

Bilateral air entry present

Dull note heard on percussion 

Vocal resonance decreased.

Cvs examination

S1 s2 heard, no murmurs

Jugular venous pressure:

https://youtube.com/shorts/nx6XLEUBxJY?feature =share

CNS examination:

No focal neurological deficits

Higher mental functions normal

Cranial nerves normal

Sensory examination normal

Motor examination normal

Reflexes normal.

INVESTIGATIONS:

14/03

Serum electrolytes:

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.

COMPLETE URINE EXAMINATION:

Colour pale yellow

Appearance: clear

Acidic

Specific gravity 1.010

Albumin ++

RBC: 4-6

No sugar, bile salts, bile pigments,  casts, amorphous deposits

Pus cells 3 to4 \hpf

Epithelial cells 2 to 3 \hpf

ULTRASOUND ABDOMEN:

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

Moderate ascites

Bilateral pleural effusion

Moderate pericardial effusion

Bilateral grade 2 rpd change

COMPLETE BLOOD PICTURE:

14/03:

Hb- 6.8g%

Wbc-5,400

Platelet:1,20,000

Pcv:23.3

MCv:77.4

Mch:22.6

Mchc:29.2

Rdw:20.1

RBC:3,01

Smear- Anisopoikilocytosis,with microcytes ,tear drop cells ,pencil forms.

15/03:

COMPLETE BLOOD PICTURE: 

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

 16/03:

Hb-7.2g%

Pcv-23.7

Mcv-70

Mch: 22.1

Mchc:20.4

Rdw:20.

15/3:

Serum creatinine 1.0 mg\dl

Serum electrolytes:

Sodium 1.37 meq\l

Potassium 4.7

Chloride 104

Spot urine protein :393 mg\dl

Spot urine creat 37.8 mg\dl.

Chest X ray:

ECG:

PROVISIONAL DIAGNOSIS :

Autoimmune disease?

Glomerulonephritis secondary to Lupus.

CLINICAL IMAGES

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 .

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SHORT CASE 

A 25 year old male patient resident of Yadagirigutta mestri by occupation presented with chief complaints of

Abdominal distension since 6days

Shortness of Breath since 6 days

Yellowish discoloration of sclera since 6days

HISTORY OF PRESENTING ILLNESS:

patient was apparently asyptomatic 4 months back then In April he had fever ,jaundice for 3 days , fever  is not associated with chills and rigor ,no evening rise of temperature he went to hospital , used medication for 1week.

Symptoms subsided  after a week ,he started to consume alcohol(180 ml) daily  since then .

In the month of June he had  Abdominal distension, yellowish decolorisation of sclera , went to a hospital in jangaon took ayurvedic medicine for 1 week , symptoms subsided.

Then he presented on now with complains of Abdominal distension since 6days, Shortness of Breath Gradelll ,fever not associated with Chills and rigor without evening rise of temperature, Altered sleep cycle,facial puffiness,, pedal edema since 3days.

Ascitic tap was done .

PAST HISTORY:

Not a known case of Diabetes mellitus, Hypertension, Epilepsy,Asthma, Tuberculosis, Coronary artery Disease.

No surgeries underwent in the past.

FAMILY HISTORY

 No member of the family has similar complaints.

PERSONAL HISTORY

Appetite- decreased

Diet - Mixed

Bowel& Bladder- Regular

Sleep-Disturbed

Addictions: Alcohol since 10 years  daily 180 ml 

Cigarette 12 / day since 10 years

No known allergies for drugs,food.

GENERAL EXAMINATION:

Patient was conscious, coherent, cooperative poorly bulit and modeately nourished ,

Pallor- cannot be examined due to Yellowish discoloration.

Icterus- present

On the day of admission.

On the next day

cyanosis: Absent

Clubbing: absent

Generalised Lymphadenopathy: Absent

Pedal edema : absent

Vitals:

Temperature

Heart rate:94beats/ min

Blood pressure:118/76 mmHg

Respiratory rate:19 cycles/ min

SYSTEMIC EXAMINATION

Abdomen :

Soft and non tender, Distended.

Inspection: Abdomen distended

 No scars,sinuses.

Umblicus  inverted

No dilated veins

Palpation: All inspectors findings are confirmed Abdomen  is soft and non tender

No visible pulsations

Hepatomegaly

Spleen

Percussion:

Resonant note heard

Shifting dullness present

Auscultation:

Bowel sounds heard.

Respiratory system:

Inspection:

Shape of chest:Barrel shaped

Gynaecomastia present 

A scar present over the rt side

Trachea : central

Wheeze is heard

Palpation:

All inspectors findings are confirmed by palpation

Chest movements: Symmetical

Tactile vocal fremitus

Tidal percussion

Percussion:

Dull note in 6th ICS 

Resonant note in 5th ICS.

Resonant note elsewhere .

Auscultation:

Breath sounds heard.

Cardiovascular system

S1 S2 heard No murmurs.

Central nervous system:

No focal neurological  deficits,all cranial nerves intact .

PROVISIONAL DIAGNOSIS:

Decompensated liver disease with Ascites .

INVESTIGATIONS:

Liver function test:

Prothrombin time:

Activated plasma thromboplastin time:

Renal function test:

Colour Doppler 2D Echo:

ULTRA SOUND OF ABDOMEN:

Ecg:

CHEST X Ray : PA View

Upper GI Endoscopy:

Apraxia Chart:

Ascitic Tap was done on  under aseptic conditions:

TREATMENT:

1. FLUID RESTRICTION.

2. SALT RESTRICTED NORMAL DIET.

3. INJ. CEFOTAXIM 2 GRAM TWICE DAILY INTRAVENOUSLY.

4. INJ. VIT K 1 AMP IN 100 ML NS ONCE DAILY  INTRAVENOUSLY.

5. INJ. THIAMINE 1 AMP IN 100 ML NS ONCE DAILY INTRAVENOUSLY.

6. INJ. PAN 40 MG TWICE DAILY INTRAVENOUSLY.

7. INJ. ZOFER 4 MG THRICE DAILY INTRAVENOUSLY.

8. TAB. PCM 650 mg SOS (<1 GRAM / DAY).

9. SYP. LACTULOSE 15 ML 30 MINUTES BEFORE FOOD THRICE DAILY.