1801006065 CASE PRESENTATION

LONG CASE

CHIEF COMPLAINTS:

A 40year old female came to OPD with chief complaints of

Body pains since 6months

Weakness of lower limbs since 6months

Difficulty in walking since 6months

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3years back than she developed weakness in left lower limb which is sudden in onset and gradually progressive in nature for which she consulted a local doctor where she was found to be having low potassium levels. She was kept on potassium supplements then the weakness got resolved.

Later in Nov 2021 she had an episode of upper and lower limb weakness with loss of consciousness and loss of speech for 2 days.She also has history of decreased bowel and bladder movements .She was again diagnosed with hypokalaemia for which she was supplemented with potassium and was on ventilation.

1 unit of blood transfusion was done than she got recovered within 5days.

In may 2022 she has similar complaints as past but it is less severe.She was again treated for hypokalaemia and got recovered within 3 days.

In Feb 2023 she has similar complaints as past with history of 2 episodes of vomiting which is non bilious ,non projectile and food particles as content.After she got admitted into hospital she noticed a swelling at parotid region on left side and dry mouth for which she was referred to dental where medication was given and swelling got subsided.Then biopsy was taken from the lower lip.

She also has dry eyes with burning sensation , dry skin with no itching.

Then in march 2023 when she came for follow up ,she was referred to ophthalmology and orthopaedics department.

At present she has body pains and difficulty in walking.

No history of fever ,cough ,itching ,numbness and tingling sensation ,complexion changes ,dental caries and oral thrush.

PAST HISTORY:

Not a known case of Diabetes, Hypertension,Asthma ,TB ,epilepsy, CAD

DRUG HISTORY:

She was on anti rheumatoid drugs and potassium syrup since 3years.

Potklor syrup since 3 years

FAMILY HISTORY:

No significant family history.

PERSONAL HISTORY:

She used to work as a daily wage labourer but stopped working 3years back due to weakness.

Appetite: normal

Diet : mixed

Bowel and bladder movements: regular with medication

Sleep: adequate

No addictions

GENERAL PHYSICAL EXAMINATION:

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

Moderately built and nourished

No signs of pallor , icterus , cyanosis ,clubbing , lymphadenopathy ,pedal edema.

VITALS:

Temperature:Afebrile

Blood pressure: 110/70 mmHg

Pulse rate: 88bpm

Respiratory rate: 18cpm

SPO2:90

Gait video:

https://youtube.com/shorts/dQJa1e6VtcE?feature=share

SYSTEMIC EXAMINATION:

CVS:

No visible pulsations, scars, engorged veins.

No rise in jvp
Apex beat is felt at 5 Intercostal space medial to mid clavicular line.

S1 S2 heard . No murmurs.

RESPIRATORY SYSTEM:

Shape of chest is elliptical, b/l symmetrical.

Trachea is central. Expansion of chest is symmetrical
Bilateral Airway Entry - positive
Normal vesicular breath sounds

ABDOMEN:

On inspection - abdomen is flat & symmetrical
Umbilicus is central and inverted
No scars, sinuses & engorged veins seen.
All 9 regions of abdomen are equally moving with respiration
On palpation - abdomen is soft and non tender
On percussion - no shifting dullness, no fluid thrill
On auscultation - normal bowel sounds are heard

CNS:

Sensory system - intact

Motor system -

Less power

Normal tone

No focal neurological deficits

Speech - normal

PROVISIONAL DIAGNOSIS:

Recurrent hypokalaemic paralysis

Secondary to distal Renal tubular acidosis

Sjögren’s syndrome

Rheumatoid arthritis

INVESTIGATIONS:

Serum electrolytes on 1/2/23

Sodium:142mmol/L

Potassium: 1.8mmol/L

Chloride:108mmol/L

Serum calcium:9.8mg/dl

Serum creatinine:1.3mg/dl

Blood urea:29mg/dl

Urinary calcium:3.0mg/day
Spot urine sodium:60mEq/L
Spot urinary potassium:12.0mEq/L

On march 13th

Hb:9.6g/dl

ESR:30mm/hr

Serum creatinine:1.1mg/dl

Serum potassium:4mmol/L

SGOT:23IU/L

SGPT:16IU/L

On march 15th

ESR:36mm/hr

Serum sodium:139mmol/L

Serum potassium:3.06mmol/L

Serum chloride:114mmol/L

Complement C3:114mg/dl (90-180mg/dl normal)

Complement C4 :63mg/dl (10-40 mg/dl normal)

Serum creatinine:0.99mg/dl

SGOT: 15IU/L

SGPT:11IU/L

On march 16th

RBS-122mg/dl

Serum magnesium: 2.1mg/dl

RA factor - positive

(48 IU|ml)

Serum calcium-9.2mg/dl

BIOPSY REPORT:

Histopathological Findings:

H and E stained section shows the presence of multiples lobules of minor salivary gland tissue consisting of normal appearing mucous acini with intralobular and interlobar ducts. The salivary gland tissue also shows the presence of multiple foci (25) of

lymphocytic infiltrate, endothelial lined blood vessels and hemorrhagic areas .

Correlating with clinical features, the above histopathological features are suggestive of Sjögren’s syndrome.

TREATMENT:

Tab NODOSIS

Syrup POTKLOR 15ml po/TID

TAB PREGABA M 75mg

Tab PANTOP

Tab HCQ 200mg

Tab WYSOLONE 10mg OD
Tab NAPROXEN 250mg

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SHORT CASE

CHIEF COMPLAINTS:

A 45 year old male who is a resident of Nalgonda and Sheperd by occupation presented to the opd with chief complaints of shortness of breath and cough since 6 years
abdominal distention , facial puffiness , pedal edema since 3 years.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 6 year back and then he developed shortness of breath which is insidious in onset gradually progressive which is initially grade 2 then progressed to grade 3 .
Then he developed cough which is productive with sputum which is yellow in colour and non blood stained
There is history of abdominal distention since 3 years which is insidious in onset and gradually progressive then he consulted a local doctor and used medications but then its not relieved and continued to progress for which he came here .
He also has history of facial puffiness and pedal edema for which he is on medications .
History of constipation since 1 year .
No history of vomiting , fever, jaundice , orthopnoea , PND, chest pain , palpitations , weight loss.

DAILY ROUTINE:

He wakes up in the morning by 6'o clock and goes to the work by 9'o clock after having breakfast and he will have his lunch by 1 in the afternoon and continues with the work then he goes back to home by 6 pm in the evening .

PAST HISTORY:

No similar complaints in the past
Not a known case of diabetes , hypertension , asthma, TB, epilepsy
He has a H/o liver infection 1year ago which had got relieved with medication.

TREATMENT HISTORY:

Right IOL implantation in 2021

FAMILY HISTORY:

Not relevant

PERSONAL HISTORY:

Diet : mixed
Appetite-normal
Sleep-inadequate
Bowel and bladder movements-constipation since 1year,urine output is normal
Addictions-He had H/o alcohol intake since his childhood and abstinence of alcohol from 1year
H/o smoking since childhood 18 cigars per day

GENERAL EXAMINATION:

Patient is conscious,coherent,cooperative and well oriented to time and place.
Moderately built and nourished
Bp:130/70 mm/hg
PR:88/min
RR: 17 cpm
Temperature: afebrile
HR: 74 bpm
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy:absent
Pedal edema: B/L pedal edema is present
Spo2: 96%
GRBS: 205 mg/dl

SYSTEMIC EXAMINATION:

CVS:
S1,S2 heard ,no murmurs
RS:
Grade 3 dyspnoea,expiratory wheeze is present
Patient examined in sitting position

Inspection:-
Shape of chest - funnel chest(Pectus excavation)
Chest movements : reduced on both sides
Trachea is central in position.

Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS,
Chest movements bilaterally symmetrical

Auscultation:
BAE+, NVBS

Abdomen:
Abdominal distention present
Umbilical hernia is present (everted umbilicus)
Fluid thrill is absent but there is shifting of dullness
No tenderness and no palpable mass
Bowel sounds are not heard
Liver and spleen are not palpable

CNS:
No focal neurological deficits

PROVISIONAL DIAGNOSIS:

Ascites

INVESTIGATIONS:

Ascitic fluid tap was done

SAAG:
Serum albumin : 2.1 g/dl
Ascitic albumin : 0.22 g/dl
SAAG: 1.79
Ascitic fluid protein sugar :
Sugar -166 mg/dl
Protein -2 g/dl
Ascitic fluid amylase :20.3IU/L
Ascitic fluid for LDH : 150 IU/L

LFT:

Total Bilirubin-4.75mg/dl
Direct Bilirubin-2.11mg/dl
SGOT(A ST)-70IU/L
SGP T(ALT)-50IU/L
ALKALINE PHOSPHATASE-200IU/L
TOTAL PROTEINS -6.2g/dl
ALBUMIN-2.01g/dl
A/G ratio-0.48

FBS- 143mg/dl
PLBS- 217mg/dl

USG and 2D echo was done