1801006094 CASE PRESENTATION
Long Case
13 Y/F came to OPD with chief complaints of
* Shortness of breath since yesterday
* 4 episodes of vomitings (since 10 am , yesterday)
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic till the age of 11years when she noticed bilateral multiple neck swellings ,non mobile associated with pain.
She was taken to local hospital with complaints of neck swellings,fever and cough (on and off)
They initiated her on ATT( Anti tubercular drugs) as her mother has also has kochs
She used ATT for 2months started in 2021 june
After initiating ATT, fever did not subside, so they stopped ATT and was referred to Hyderabad.
Patient was taken to X hospital where she was evaluated for kochs but none of the investigations showed Acid fast bacilli.
At the same time she also had complaints of knee pains and wrist joint pains
In view of joint pains she was referred to Y hospital
In Y hospital they suspected it to be AUTOIMMUNE
And started her on
Tab Wysolone
Tab Hydroxychloroquine
which she used for 15 days and stopped ( symptoms subsides) and later did not go there for follow up
(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 May 2022 ?reactive(no report available but attendor was informed that it was negative for kochs)
So Mycobacterial gene expert test was done on blood sample which was also negative
But she was initiated on ATT empirically on may/2022.
In June 2022 she started developing pigmentation/rash over face which then was seen on scalp evident because of hair loss and on trunk since 3 months,not associated with itching.
And also pedal edema upto ankles which then progressed till knee in the last 3 months(pitting type)
Then she was taken to area hospital and got tested and the attender(father) was informed that she has tuberculosis.
Lymph node biopsy was done
Mycobacterial gene expert test was done
No reports available
So they started her on ATT and recieved regular treatment for 6m.
Her symptoms settled and she was fine until January 10 when she develop edema again (generalized)
They went to another hospital and got tested and was told to have proteinuria.
In January and February she had mild fever and 1 week back she developed fever and edema again.
On 13 March
From 10 am in the morning
Patient had 4 episodes of vomitings, after 2 hrs of food intake , non bilious and non blood stained, food particles and water as content.
She also complains of nausea
Patient later on the same day developed shortness of breath of Grade 3 ( NYHA)
PAST HISTORY
K/C/o e
Extra pulmonary tuberculosis (1year back used att for 6 months)
N/k/c/o hypertension, Diabetes mellitus, epilepsy, asthma, coronary artery disease, cardiovascular disease.
TREATMENT HISTORY
Used ATT for 6 months for TB
Birth and Family history
1st child
2nd degree consanguineous marriage
Born in 2010
LSCS
Father has no idea about immunisation status
Mother-has 2 children
The current pt is the elder one(birth in 2010)
2nd child born in 2013
In 2014 mother diagnosed with kochs - expired in 2022 sept(did not use ATT regularly)
PERSONAL HISTORY
Single
Occupation:student
Diet - Mixed
Appetite - Decreased
Sleep - Adequate
Bowel and bladder - Regular
No addictions.
DAILY ACTIVITY
Earlier at Hostel
5 am wake up
Gets ready by 6 am
6:30 am to the ground for yoga,exercises
7 am ragi Java
7.30 am prayer
8am classes
9.15 am breakfast
Classes until 1.30
1.30 to 2.30 lunch
2.30 to 4.30 study hour
4.30 to 5 snacks
5.00 to 6 pm walking ,playing
6 to 6.30 prayer
7 pm dinner
Till 9 pm study hour
9pm sleep
Now at Home
6am wake up
7 am tea
Breakfast and fruits
Tablets
Sleeps until afternoon
2.30 to 3 lunch
2 months after taking ATT her appetite was increased and she ate more food ,more frequently (5times a day).
Walking exercises
Evening 6pm fruits
Songs prayers
8pm dinner
9pm sleep
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative,well oriented to time,place and person.
Moderately build and malnourished.
Examination was done in a well lit room.
Pallor+
Pedal edema + ( grade 2)
No icterus, cyanosis,clubbing,lymphadenopathy
VITALS
BP:140/90 bpm
PULSE RATE:80/min regular normal volume
RESPIRATORY RATE: 26 cycles/min
Spo2 : 95%RA
Temperature chart
SYSTEMIC EXAMINATION
ABDOMEN
Inspection
Shape - Slightly distention.
Umbilicus - Everted
Equal movements in all the quadrants with respiration.
No visible pulsation,peristalsis, dilated veins and localized swellings.
No scars , sinuses
Palpation
Soft, tenderness in right and left Hypochondrium, epigastrium.
Fluid thrill present
Percussion
Shifting dullness present
Auscultation
Bowel sounds heard
RESPIRATORY SYSTEM
Bilateral air entry present
Dull note all over
Vocal resonance decreased
CVS EXAMINATION
S1 S2 heard( Slightly muffled), no murmurs
Pericardial rub heard
CNS EXAMINATION
No focal neurological deficits
Higher mental functions normal
Cranial nerves normal
Sensory examination normal sensations
Motor examination normal
Reflexes normal
INVESTIGATIONS
Spot urine sodium 166mmol/l
Spot urinary potassium 20.5
ABG
PH 7.4
Pc02 14.9 mm hg
P02 79.8mm hg
Hc03 9.2 mmol/l
O2 saturation 96%
SERUM ELECTROLYTES on 14\3
Sodium 136 meq/l
Potassium 4.4 mEq/l
Chloride 106 meq/l
Serum creatinine 0.6mg/dl
ESR 70 mm
CRP NEGATIVE
Blood urea 29 mg\dl
FBS 100 mg\dl
Blood group 0+
Rheumatoid factor negative
HIV non reactive
Hbs ag non reactive
URINE EXAMINATION
Colour pale yellow
Appearance clear
Acidic
Specific gravity 1.010
Albumin ++
No sugar, bile salts, bile pigments, rbc, crystals, casts, amorphous deposits
Pus cells 3 to 4 \hpf
Epithelial cells 2 to 3 \hpf
USG
Liver,gallbladder,pancreas,spleen, uterus,ovaries normal
Moderate ascites
Bilateral pleural effusion
Moderate pericardial effusion
Bilateral grade 2 RPD changes
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
On 15\3
Serum creatinine 1.0 mg\dl
Sodium 1.37 meq\l
Potassium 4.7
Chloride 104
Spot urine protein 393 mg\dl
Spot urine creat 37.8 mg\dl
Ratio 10.3
ECG
TREATMENT
Fluid restriction ( 1.5 L/day)
Salt restriction (1.2 GM/day)
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
----------------------------------------------------------------------------------------------------------------------------------------------------
Short Case
A 55yr old male came with the chief complaints of
*Tingling and Burning sensation in left leg and left hand since 15 days
*Chest pain since 6days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6yrs ago then he had an episode of sudden loss of consciousness associated with excessive sweating, which was associated with slurring of speech, deviation of mouth towards right.
He was taken to hospital in karimnagar and diagnosed with left hemiparesis and is under medication (anti platelets) till date.
He now presents with the complaint of burning sensation in the left upper and lower limb since 15 days which is persistent throughout day.
He also complains of right sided chest pain which is sudden onset ,dragging type , non radiating, intermittent in nature not associated with shortness of breath ,sweating .
Patient complaints of generalized weakness since 1 year
No history of any other episodes of loss of consciousness, seizures,headache , nausea,vomitings .
PAST HISTORY
Patient had a history of trauma to head 20 years ago( was beaten up by thieves)
For which suture were done and medications were taken
Not a known case of DM,HTN,Epilepsy,Asthma and coronary artery disease.
H/o Right eye cataract surgery 1 year ago .
VITALS
TEMPARATURE:Afebrile
BP:140/90 bpm
PULSE RATE:80/min regular normal volume
RESPIRATORY RATE:16 cycles/min
Spo2 : 95%RA
CENTRAL NERVOUS SYSTEM:
Conscious and coherent
Right handed
HIGHER MENTAL FUNCTIONS Intact.
MMSE 24/30
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : Visual acuity is normal
3rd,4th,6th : Pupillary reflexes present
EOM full range of motion present
5th : Sensory intact
Motor intact
7th : There is absence of nasolabial fold in left side and slight deviation of mouth towards right .
8th : No abnormality noted.
9th,10th,11th,12th : normal.
MOTOR EXAMINATION:
Right Left
UL LL UL LL
BULK: Normal Normal Wasting in both
TONE : Normal Normal Hypertonic in both
POWER : 5/5. 5/5. 3/5. 3/5
SUPERFICIAL REFLEXES:
CORNEAL present
CONJUNCTIVAL present
DEEP TENDON REFLEXES:
Right Left
BICEPS. + 2 + 3
TRICEPS + 2 + 3
KNEE + 3 +3
ANKLE + 2 +3
PLANTAR Flexion Extension
https://youtube.com/shorts/MWi6csdneKI?feature=share4
https://youtube.com/shorts/L9VKzyXRt_w?feature=share4
https://youtube.com/shorts/3R5VfOPGimY?feature=share4
SENSORY EXAMINATION:
Left Hemiparesis associated with UMN Facial palsy ( left side of face)
Acute ischemic stroke in right MCA territory??
INVESTIGATION
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