1801006071 CASE PRESENTATION
long case
55 year old Female patient who is resident of Chityal came to OPD with
CHIEF COMPLAINTS:
Fever since 13 days back
Pain in Abdomen since 10 days back
HISTORY OF PRESENTING ILLNESS:
Patient was apparently a symptomatic 3 months back then she developed itching over the right leg then after due to scratching she developed leg swelling upto ankle for which she went to local RMP doctor then he gave intramuscular injection at left buttock for which she develop swelling, eventually she developed pustule over the injection site and progressed to form ulcer.
History of fever since 13 days which is insidious in onset,low grade,intermittent associated with chills and rigor.Fever is associated with cough with sputum scanty in amount,non blood stained ,mucoid in nature.No histoty of loose stools,cold,Burning sensation.History of decreased urine output no history of dribbling of urine,urgency.
After 3 days,she developed pain in abdomen which is insidious in onset gradually progressive,the pain is localized to the upper abdomen, pricking type of pain, non radiating with no aggravating or relieving factors.she also developed Shortness of Breath which is grade 3 which is not associated with Orthopnea and Paroxysmal nocturnal Dyspnea.No History of Vomiting,loose stools.
She was taken to local hospital.She was found to be having some kidney problem and given medication.
After that Shortness of breath is subsided but fever is intermittent and pain is resolved.Pain became severe.She brought to our hospital for further evaluation.
On admissiom day there is history of Vomiting, 2 episodes ,watery in consistency with no food particles, non bilious, non blood stained.
PAST HISTORY:
She is hypertensive since 3 years and she is on regular medication.
No History of Diabetes,Asthma,Tuberculosis,Leprosy,Epilepsy.
PERSONAL HISTORY:
She is mother of 5 childern(3 females and 2 male).She lives with her husband.She wakes up at 6:30AM. At 8 she has breakfast which she usually she take rice and curry. She gets ready and goes to the local market to sell lemons. She takes a lunchbox and has her lunch there which again consists of rice and curry. Around 5 PM she comes back to her house. She does her daily chores.She has dinner at around 8PM and goes to bed at 9PM.
Diet:Mixed
Appetite:Reduced
Sleep: Reduced since 10 days.
Bowel movement:regular
Bladder movement:reduced since 10days
Addiction:she regularly take toddy every day since 10 years and every 3days she used to take alcohol
FAMILY HISTORY:
No relevant Family history.
Fever chart:
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative. Well oriented to time place and person. Moderately built and nourished. Pallor present.No Icterus, cyanosis, clubbing, lymphadenopathy.Mild edema present.
Ulcer:
VITALS:
Pulse - 74 beats per minute.
BP - 110/80 mm Hg
RR - 18 Cycles per minute
Temp- 98.3°C.
SYSTEMIC EXAMINATION:
ABDOMEN:
INSPECTION:
Shape is round,Generalized Distension is seen
Umbilicus is Inverted.
Equal symmetrical movements in all the quadrants with respiration.
Scar is visible.
No visible pulsations,peristalsis,visible swelling, dilated veins are seen.
PALPATION:
Tenderness is noted in Right hypochondrium region.No local rise of temperature,No Rigidity and Guarding is seen.
LIVER:
Enlarged, soft in consistency smooth surface,rounded edges, tender, non pulsatile
No spleenomegaly.
Abdominal girth :-106cm.
PERCUSSION:
Hepatomegaly :
liver span of 15 cms with 4 cms extending below the costal margin
Fluid thrill and shifting dullness absent
Tympanic note is present
ASCULTATION:
Bowel sounds heard.
No venous hum or bruit.
CVS:
Inspection:
Position of the trachea is central.
Apical impulse is not observed.
No other visible pulsations, dilated and engorged veins,sinuses.
Palpation:
Apex beat was localised.
Position of trachea was central
No parasternal heave , thrills, tender points.
Auscultation:
S1 and S2 were heard
There were no added sounds / murmurs.
Respiratory system:
Trachea central
Bilateral air entry is present
Normal vesicular breath sounds are heard.
Resonant on percussion.
CNS:
Higher mental functions-
Normal
Memory intact
Cranial nerves :intact
Sensory Examination:
Normal
Motor Examination:
Normal tone in both limbs
Normal power in both limbs
Reflexes:
Right Left
Biceps 2+ 2+
Triceps 2+ 2+
Knee 2+ 2+
Ankle 2+ 2+
INVESTIGATIONS:
17th march
Complete blood picture:
Haemoglobin:9.6 g%
Red blood cells:3.1 million/mm3
Pcv:29.6 vol%
Platelet count:6.6.lakhs/mm3
Total leucocyte count:15,600/mm3
Blood urea 60mg/dl
Sr creatinine 1.0 mg/dl
serum Na 133mmol/dl
Serum K 3.6mmol/dl
Serum Cl 99 mmol/dl
complete urine examination:
Color-pale yellow
Appearance- clear
Specific gravity-1.010
Sugar-nil
Albumin:Trace
Pus cells:2-4hpf
Epithelial cells-2-3/hpf.
16th March
Blood urea-70 mg/dl
Serum creatinine -1.1mg/dl
Serum sodium-132meq/dl
Serum potassium-3.2meq/dl
Serum chloride-98meq/lt
complete urine examination:
Color-pale yellow
Appearance- clear
Specific gravity-1.010
Sugar-nil
Albumin:Trace
pus cells:2-4hpf
15th march
Serum creatinine :1.6mg/dl
14th march:
Total bilirubin:2.6 mg/dl
Direct bilirubin: 1.1 mg/dl
Indirect bilirubin:1.5mg/dl
Alkaline phosphatase:193IU
AST:37 IU
ALT:21 IU
Protein total: 7.0 g/dL
Albumin:4.3g/dl
Globulin:2.7 g/dl
Albumin and globulin ratio:1.6
Serum creatinine:2.1mg/dl
13th March:
Complete Blood picture:
Haemoglobin:11.7 g%
Red blood cells:3.81 million/mm3
Pcv:32.5 %
Platelet count:5.0 lakhs/mm3
Total leucocyte count:22,400 /mm3
Blood urea 58 mg/dl
Sr creatinine 1.9 mg/dl
serum Na 127 mmol/dl
Serum K 3.4 mmol/dl
Serum Cl 92 mmol/dl
Lipid profile:
Total cholesterol:218mg/dl
Triglycerides:240mg/dl
HDL cholestrol:54 mg/dl
LDL cholestrol:116mg/dl
VLDL Cholestrol:48mg/dl
ECG:
USG Abdomen:
Findings- 5 mm calculus noted in gall bladder with GB sludge
Impression- Cholelithiasis with GB sludge
Grade 2 fatty liver with hepatomegaly .
DIAGNOSIS:
Acute Cholecystitis with Hepatomegaly
,Acute Kidney Injury
Left Gluteal Abscess.
TREATMENT:
Inj PAN 40 mg iv/ od
Inj PIPTAZ 2.25mg/iv/TID
Inj. METROGYL 500mg / iv/tid
Inj zofer 4mg iv/sos
INJ NEOMOL 1gm iv/sos
T.PCM 650mg po/tid
T.CINOD 10mg po/od
Iv fluids 1 unit NS, RL, DNS 100 ml/hr
Pneumatic compressor bed.
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short case
A 45 yr old female home maker by occupation presented to opd with chief complaints of shortness of breath since 15 days
History of Presenting illness:
Patient was apparently asymptomatic 15 days ago . Then she developed shortness of breath which was insidious in onset gradually progressive and aggravated on stress, work(Class 2 NYHA ) and relieved on rest.Within to few days of onset of her shortness of breath it progressed to her unable to perform her daily activities( Class 3) so she went to local hospital were her haemoglobin levels were found to be low (3.6) and she was advised to our hospital for blood transfusion.
No history of chest pain , sudden grasping of air at night,Orthopnea.
Past History:
She had a previous blood transfusion of 3 packs 1 yr back since on her hospital visit for menoragghia she was found to be having low haemglobin
Known diabetic since hospital admission.
Not a known case of hypertension, epilepsy ,Asthma, coronary artery disease or chronic kidney disease.
Menstrual history:
Age of menarche 12 yrs
Previous cycles were 3/30 with no pain and clots
Since 1 yr she is having 5/20 with heavy menstrual bleeding with no pains and clots and she went to hospital and was diagnosed with fibroids and was advised hysterectomy and then on routine investigations because of her low hb surgery was postponed and she was given blood transfusions and her hb raised to 8 gm% which was not adequate for surgery and as she qas approaching menopause on advise of her relatives she didnt want surgery
Personal History:
Diet Mixed
Appetite normal
Bladder and bowel movements regular
Sleep adequate
Allergies none
Addictions none
Family History-
Not significant
Clinical Images:
GENERAL EXAMINATION-
Patient is conscious coherent and co operative well oriented to time place and person moderately built and nourished.
Pallor-present
Icterus - Absent
Clubbing- Absent
Cyanosis- Absent
Lymphadenopathy- Absent
Edema - B/l on both lower limbs till knees pitting type
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Vitals:
Systemic Examination:
CVS
Inspection:
Position of the trachea is central.
Apical impulse is observed.
No visible pulsations, dilated and engorged veins, scars.
Palpation:
Apex beat was localised in the 5th intercostal space 1cm lateral to mid clavicular line.
Position of trachea was central
No parasternal heave , thrills.
Auscultation:
S1 and S2 were heard
No murmurs.
Respiratory system:
Bilateral air entry is present
Normal vesicular breath sounds are heard
PER ABDOMEN-
Soft non tender
No organomegaly
C section scar visible.
CNS -
No focal neurological deficit.
Investigations:
Complete Blood Picture:
Hemoglobin:3.6gm%
RBC 2.11 million/mm3
MCV:73.5 fl
MCH:17.1 pg
MCHC: 23.2 %
PCV:15.5 vol%
Peripheral smear:
Anisopoikilocytosis with Macrocytes,Macro ovulacytes,Microcytes pencil drops and tear drops.
Complete urine examination:
Color-pale yellow
Appearance- clear
Specific gravity-1.010
Sugar-nil
Albumin:+++
Pus cells:4-8hpf
Epithelial cells-3-4/hpf
ECG:
Provisional Diagnosis:
Dimorphic anemia
Heart Failure secondary to anemia.
Treatment:
Transfuse Packed Red blood cells
Tab Order Xt
Inj Vitamin B12
Inj Lasix 40mg .
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