1801006076 CASE PRESENTATION

LONG CASE 

 A 29 year old female know case of SLE , customer service executor by occupation, resident of akkinepalli.

CHEIF COMPLAINTS :

- Swelling Of Both Legs Since 3 days

- Swelling Of Both Eyes Since 3 days

HISTORY OF PRESENTING ILLNESS :

PAST HISTORY :

Diagnosed with hypertension 5 months back ( on November 2022 secondary to kidney failure) and on regular medication.

Not a known case of diabetes mellitus, tuberculosis, thyroid disorders, epilepsy 

PERSONAL HISTORY :

Her Daily routine day starts at 7 AM ,she used to get ready for  work and went to office at 8 AM ,used have breakfast at office at around 10 am ,her work was more of  attending client calls with 1 to 2 breaks in between till 6 PM more of sedentary work ,sleeps at 11 pm .But since one month she is staying in home ,she quit her job due to regular dialysis.

Diet - mixed

Appetite - loss of appetite

Sleep- adequate

Bowel and bladder - bowel regular, reduced urine output 

No Addictions 

FAMILY HISTORY :

Mother is known diabetic

No history of autoimmune diseases in the family. 

MENSTRUAL HISTROY:

Age of menarche:12 years.

Menstrual cycles :Her Menstrual cycles were irregular since 2 months. 

Her last Menstrual period was Dec 25th 2022 

Obstetric history:- para 1live 1 

GENERAL EXAMINATION :

Patient is conscious, coherent, cooperative

Well oriented to time place and person, moderately nourished thin built.

Pallor - Present

Icterus, cyanosis, clubbing, generalized lymphadenopathy are absent

Bilateral pedal edema present, pitting type

SYSTEMIC EXAMINATION :

CVS: 

S1 ,S2 present

No murmurs 

RESPIRATORY SYSTEM :

Bilateral air entry present 

Normal vesicular breath sounds heard 

No dyspnoea and no wheeze 

ABDOMINAL EXAMINATION :

Shape of abdomen: scaphoid

Liver and spleen are not palpable 

CNS:

Patient is conscious 

Speech: normal 

Cranial nerves: normal

Motor and sensory system: normal 

Glassgow coma scale: E4 V5 M6

INVESTIGATIONS:

15.03.2023

Blood urea -79 mg/dl (N=12 to 42 mg/dl)

Serum creatinine-4mg/dl(N0.6 to 1.1)

Serum electrolytes-

Na :141mEq/L(N-136 to 145)

K:3.5mEq/L(N:3.5 to 5.1)

Cl:102mEq/L(N=98 to 107)

Ionized ca+2:1.01mmol/L.

14.02.2023

HEMOGRAM:

Hb 8.5gm/dl.

Total count:12000 cell /cumm

Neutrophils:83 %

Lymphocytes:11%

Pcv:24.3 volume %

Platelets :l.lL / cumm.

Impression :Normocytic normochromic anemia  with neutrophilic lymphocytes and thrombocytopenia.

Renal function test:

Urea:157mg/dl

Creatinine :6.9 mg/dl.

Uric acid :6.5 mg/dl.

ECG:-

PROVISIONAL DIAGNOSIS :

Chronic renal failure secondary to lupus nephritis on maintaining hemodialysis.

TREATMENT :

Tab Nicardia 30mg,po/tid

Tab lasix 40mg , po/bd .

Tab wysolone,po/bd.

Tab azathioprine 50 mg po/ od

Tab hydroxychloroquine 200mg po/od. 

Tab Met xL 25 mg ,po/od. 

Tab nodosis 500mg po/od.

Tablet  shelcal 500mg po/od

Tab orofer xt po/od

Tab Pan 40mg po/od.

Tab biod3 po/ weekly twice . 

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SHORT CASE 

CASE PRESENTATION

27 yr old male came with complaints of

Generalised weakness since 10 days

Difficulty in breathing since 10 days

Easy fatigability since 10 days

HOPI: patient was apparently asymptomatic 10 days back he developed generalised weakness insidious in onset, gradually progressive

Shortness of breath of grade 2 

Easy fatigability present

No c/o fever, nausea, vomiting, chest pain, pain abdomen, blood in stools, loose stools, sweating

1 year back, then he developed jaundice and generalised weakness for which he took herbal medicines for 10 days and was resolved.

Not a k/c/o DM/HTN/TB/ Epilepsy/CVA/CAD/Asthma

Personal history:

decreased appetite since 5-6 months

Takes vegetarian diet

Bowels and bladder habits are regular

Disturbed sleep 

Occassional alcohol drinker stopped 1 year back

General examination: patient is c/c/c

Pallor and icterus is present

No signs of cyanosis, clubbing, lymphadenopathy, pedal edema

 

VITALS :

Temp: afebrile

PR: 106 bpm

RR: 20 /min

BP: 130/90 mm hg

Systemic examination:

CVS: S1 S2 heard

RS: Bilateral air entry present

CNS: NFND

P/A: soft, non tender, no organomegaly

Bowel sounds heard

Investigations:

Hemogram :

- Hemoglobin 7.6 gm/dl

- Red cell count 2.2 ml/cu.mm

- WBC Total count 3500ml/cu.mm

Differential Count :

- Neutrophils : 55%

- Lymphocytes : 40%

- Eosinophils : 1%

- Monocytes : 4%

- Basophils : 0%

Platelet count : 1,11,000/cu.mm

Hematocrit :25.3%

MCV : 115 m.micrograms

MCH : 34.5 m.micrograms

MCHC : 30%

COMPLETE URINE EXAMINATION :

Colour : Pale yellow

Appearance : Clear

Reaction : Acidic

Sp. Gravity : 1.010

Albumin : Nil

Sugar : Nil

Bile salts : Nil

Bile Pigments : Nil

Pus cells : 2-3

Epithelial cells :2-3

LFT :

Total Bilirubin : 1.02mg/dl

Direct Bilirubin : 0.03mg/dl

SGOT / AST : 96IU/L

SGPT/ALT : 29 IU/L

A/G ratio : 1.42

Serum Creatinine : 0.7mg/dl

Blood Urea : 24mg/dl

PERIPHERAL BLOOD SMEAR

RBC : Anisopoikilocytosis with microcytes macrocytes normocytes teardrops pencil forms

WBC : Within normal limits

Platelets : Adequate

ECG

Chest x ray

Provisional Diagnosis: 

Anemia secondary to Vitamin B12 deficiency iron deficiency (dimorphic)

 Treatment: 

Inj. VITCOFOL 1000mg/IM/OD

27 year old male came with c/o generalised weakness and shortness of breath since 10 days

S 

1 fever spike 

O

Pt is c/c/c 

BP-130/70 mmhg 

PR- 92bpm

Temp- 98.5F

CVS- S1,S2 heard, no murmurs 

RS- B/L Air entry present

P/A: soft, non-tender 

CNS: HMF intact, NFND  

A

Anemia Secondary to B-12 deficiency and Iron deficiency (Dimorphic) with Tinea Corporis ET Cruris +Statis Dermatitis

 

P: 

Inj. VITCOFOL 1000mg/IM/OD

LULIFIN CREAM L/A BD

LIQUID PARAFFIN L/A BD

TAB. TECZINE 5mg SOS