1801006061 CASE PRESENTATION

 LONG CASE 

Cheif complaints:

A 14 year old female,resident of nagarjuna sagar

Presented with cheif complaints of 

Pain in lower limbs (more in right knee) and lower back pain since 3 days 

History of presenting illness:

                     

                      

Currently ,in 2023:

She was apparently asymptomatic  3 days back then she developed pain in left ankle initially which progressed and since 1 day she developed pain in both knee (more on the right side>>left) which is of throbbing type in nature . 

Tenderness in calf muscles is present.

No aggravating and relieving factors

No history of fever ,abdominal pain

No H/o of swelling 

All the peripheral pulses are palpable

No h/o chest pain,shortness of breath,headache and palpitations 

No h/o aphasia or dysphagia, seizures,Severe headache,altered mental status

BIRTH HISTORY:

She is second born child of parents married of 3rd degree consanguinity in 2009.

 All trimesters were uneventful. 

She was delivered through Caeserean section because of delayed labour pain with birth weight of 3kg.

PAST HISTORY - 

K/C/O OF sickle cell anaemia since 2012 

H/O 8 PICU admissions

history of recurrent Bronchopneumonia , 

History of sickle cell crisis in 2016

History of pancreatitis in 2019

H/O blood transfusions - done about 20 times till now and last transfusion was done in January 2023

No H/O of asthama,thyroid,Tuberculosis, Hypertension, Diabetes,Epilepsy

No h/o of bone pain with localized swelling 

IMMUNIZATION HISTORY 

patient is immunised till date

Pneumocccal,typhoid,hepatitis vaccine taken on 23/1/22

PERSONAL HISTORY :

Diet: mixed

Appetite: normal

Sleep: adequate

Bowel and bladder movements regular

No addictions

FAMILY HISTORY - 

3rd degree consanguity of parents

No known affected relatives

GENERAL EXAMINATION:

Patient was conscious, coherent and cooperative. 

Well oriented to time, place and person.

Moderately built and nourished.

Pallor present

Icterus absent

Cyanosis, clubbing, lymphadenopathy, Pedal edema absent

Vitals

Temp: Afebrile 

PR- 96bpm    

RR- 18/Min

BP- 110/70 mmHg

SYSTEMIC EXAMINATION

P/A - Shape of abdomen- Normal. Umbilicus everted. No scars. No organomegaly. Bowel sounds heard.

CVS- S1 S2 heard, no murmurs

RS- NVBS.

CNS- No focal neurological deficits

Tone, power and reflexes are normal.

On examination on lower limbs bilateral calf tenderness is seen.

Clinical pictures: 

        

               

           

Peripheral smear:

          

X-rays:

DIAGNOSIS:

sickle cell anemia with vaso occlusive crisis 

INVESTIGATIONS 

Hemoglobin-8gm/dl

TLC-22,900

PCV-23.1(normal-36 to 46)

BLOOD group -O positive 

Total bilirubin-20.15

Direct bilirubin-14.13

SGOT-170

SGPT-180

ALP-560

CRP-negative

Serology -negative

LDH-

blood urea-20mg/dl

Creatinine-0.4

Electrtrolytes-sodiun- 136 mEq/l

                           Pottasium-4.5 mEq/l

                          Chloride-101mEq/l

                           Calcium 1.02mmol/l

Peripheral smear-

  Anisopoikilocytosis with predominant Sickle cell,normocytes,few microcytes

Platelets and wbc were raised 

CURRENT MANAGEMENT ( mainly pain management)

IVF NS and DNS

Inj PAN 40 mg/day

Inj OPTINUERON

inj DICLO

----------------------------------------------------------------------------------------------------------------------------------------------------

SHORT CASE 

CHIEF COMPLIANTS

A 64 year male patient presented with cheif compliants of:

Cough since 10 days

Loose stools since 10 days

Hiccups since 7 days

Inability to speak since 4 days 

fever 4 days back

loss of appetite since 3 days

HISTORY OF PRESENT ILLNESS

patient was apparently asymptomatic 10 days back then he developed diarrhoea -5 episodes/day for 1 day which relieved on medication.Then he developed having hiccups since 7 days and anorexia for 3days.since 25/12/22 he is unable to talk.

             

PAST HISTORY

h/o panic attack one month back secondary to family issues 

  -DM2 since 6 yrs ,

 on medication :tab Metformin OD , tab Glimiperide OD

 -NO HISTORY OF HTN, TB, Asthma, epilepsy, CAD, CVD

Personal History :- 

Appetite - reduced

Diet - Mixed 

Sleep - adequate

Bowel and bladder movements - incontinence 

Addictions: Occasional alcoholic ( during functions ) ,chews tobacco daily

Allergies : No allergies 

Family history:

Mother is a known case of TB 5years back who is treated adequately.

GENERAL EXAMINATION

Patient is unconscious ,incoherent , uncooperative

 Moderately Built and Moderately Nourished .

Pallor : present 

Icterus : absent 

Cyanosis: absent 

Clubbing : absent 

Lymphadenopathy : absent 

Edema : absent

 Vitals :- 

Temp: Afebrile 

BP : 100 / 50 mmHg 

PR : 120 bpm 

RR : 16 cpm 

SPO2 : 98 % at RA

GRBS : 193 mg/dl 

Fever chart:

SYSTEMIC EXAMINATION: 

CNS examination :-

HIGHER MENTAL FUNCTIONS

State of consciousness : unconscious 

Speech : incoherent 

Sensory system :- 

Pain - Normal 

Temp - normal

Cranial nerves :  

Not elicited patient not cooperative

CNS 

Reflexes :-

Biceps + +

Tricep s + +

Supinator + +

Knee +

Ankle. ++

Flexor. Plantar. Plantar 

Finger nose in coordination - no 

Heel knee in coordination - no

CVS : S1 S2 + ,no murmurs ,no thrills 

Respiratory System : decreased air entry on left side . Crackle sound are heard. Position of trachea - central.

Per abdominal examination:- 

Soft , non tender , no signs of organomegaly

Clinical pictures:

       

X-ray:

INVESTIGATIONS:

CSF ANALYSIS

Sugar  51 mg/dl (normal 60-90mg/dl)

Protein 203mg/dl( normal 10- 45mg/dl)

Chloride 121 mmol/L (116-127mmol/l)

CSF CELL COUNT

Colour - colour less

Appearance - slightly cloudy

Total cells - 90 cells /cumm

Lymphocytes -60%

Neutrophils - 40%

COMPLETE URINE EXAMINATION

Colour - pale yellow

Appearance - clear

Reaction - acidic

Specific gravity - 1.010

Albumin -nil

Sugar -nil

Bile salts - nil

Bile pigments- nil

Pus cells - 2-3cells(normal 0-5/HPF)

Epithelial cells- 2-3 cells(normal 0-5HPF)

RBC -nil (normal 0-5/HPF)

Crystals-nil

Casts-nil

Amorphous deposits-absent

BLOOD UREA -124mg/dl(normal 17-50mg/dl)

APTT

  

APTT TEST- 31sec(normal 24- 33sec)

Bleeding and clotting time

Bleeding time- 2min 30sec(normal2 -7 min)

Clotting time- 5min (normal 1- 9min)

PROTHROMBIN TIME - 15sec ( normal 10 -16 sec)

MRI BRAIN PLAIN 

DIFFUSE CEREBRAL ATROPHY

BLOOD SUGAR 159mg/dl 

 DIAGNOSIS 

Altered sensorium secondary to tuberculous

meningitis 

Management:-

1) IVF 0.9 %NS IV @ 50 ml / hr 

2) Inj , 1 amp Optineuron in 500 ml NS IV /OD 

3) tab Ecosprin AV 75/10 RT / OD / HS

4) GRBS monitoring 6 th hrly 

5) Inj Thiamine 200 mg IV/BD in 100 ml NS