1801006114 CASE PRESENTATION

 LONG CASE

A 23 year old female patient store manager by occupation came to general medicine OPD with 

CHIEF COMPLAINTS 

• Pain in the left side of abdomen on and off since 1 year 

HISTORY OF PRESENTING ILLNESS 

• Patient was apparently asymptomatic 9 years back the she started developing pain in left hypochondrium insidious in onset intermittent & dragging type. since last one year multiple episodes of pain every month lasting for 30-60 min.

•c/o frequent onset of fever (once in 15-20 days) since 1 year, for which she visited a local hospital and found to be having low hemoglobin & started oral iron (used for one month)

•c/o shortness of breath since one year ( Grade III MMRC)

•c/o early fatigability, tingling in upper and lower limbs 

•decreased appetite since 14 years of age 

•No H/o chest pain, pedal edema 

•No H/o orthopnea, PND 

•No H/o cold , cough 

•No bleeding manifestations 

•No c/o weight loss 

Timeline of illness 

PAST HISTORY

•Not a known case of  Hypertension , Diabetes mellitus , Tuberculosis , asthma , thyroid disorders, epilepsy , CVD , CAD 

• No H/o surgeries in the past 

FAMILY HISTORY

•No significant family history

PERSONAL HISTORY

• Diet - mixed 

• appetite - decreased

• sleep - adequate

• bowel and bladder - regular

• No addictions and no known allergies  

MENSTRUAL HISTORY 

• age of menarche - 12 yrs 

• Regular cycles , 3/28 , changes 3-4 pads per day. 

• No gynecological problems

GENERAL PHYSICAL EXAMINATION 

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

• Thin built 

• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema , 

• hyperpigmentation of tongue 

VITALS 

Temperature : afebrile

Pulse rate : 70 bpm

Blood pressure :110/70 mmHg

Respiratory rate : 18 cpm

SYSTEMIC EXAMINATION

PER ABDOMEN :

• inspection 

Shape - flat , no distention 

Umblicus - inverted, round scar around umblicus

No visible pulsations,peristalsis, dilated veins 

Visible swelling in the left hypochondrium , 6cm×4cm in size, oval shape, smooth, skin over swelling is normal 

Hernial orifices are free

• Palpation 

No local rise of temperature and tenderness

 Spleen palpable ( moderate splenomegaly) 5cm below it's costal margin

 No palpable liver 

•Percussion

liver span -12 cm 

Spleen - dullness extending to left lumbar region 

Fluid thrill and shifting dullness absent

•Auscultation 

 

Bowel sounds present 

CARDIOVASCULAR SYSTEM:

•Inspection 

Shape of chest- elliptical shaped chest

No engorged veins, scars, visible pulsations

No JVP 

•Palpation 

 

Apex beat can be palpable in 5th inter costal space medial to mid clavicular line

No thrills and parasternal heaves can be felt

•Auscultation 

S1,S2 are heard

no murmurs

 

RESPIRATORY SYSTEM:

•Inspection

Shape of the chest : elliptical 

B/L symmetrical , 

Both sides moving equally with respiration 

No scars, sinuses, engorged veins, pulsations

•Palpation

Trachea - central

Expansion of chest is symmetrical.

•Percussion

 Resonant 

•Auscultation

 B/L air entry present . Normal vesicular breath sounds 

CNS:

•HIGHER MENTAL FUNCTIONS- 

Normal

Memory intact

•CRANIAL NERVES :Normal

•SENSORY EXAMINATION

Normal sensations felt in all dermatomes

•MOTOR EXAMINATION

Normal tone in upper and lower limb

Normal power in upper and lower limb

Normal gait

•REFLEXES

Normal, brisk reflexes elicited- biceps, triceps, knee and ankle reflexes elicited

•CEREBELLAR FUNCTION

Normal function

No meningeal signs were elicited

Provisional diagnosis : anemia with splenomegaly 

INVESTIGATIONS 

 25/02/2023

HAEMOGLOBIN- 8.9 gm/dl

TOTAL COUNT - 2000 cells/cumm

pcv - 32.4

MCV - 78.6

MCHC - 27.5

RDW-CV 25.2

smear- microcytic hypochomic with leucopenia and thrombocytopenia

26/02/2023

HAEMOGLOBIN- 8.8 gm/dl

TOTAL COUNT - 2600 cells/cumm

pcv - 32.8

MCV - 79.0

MCHC - 26.8

RDW-CV 25.3 %

smear- microcytic hypochomic with leucopenia and thromobocytopenia

27/02/2023

HAEMOGLOBIN- 8.7 gm/dl

TOTAL COUNT - 2000 cells/cumm

pcv - 31.9

MCV - 78.6

MCHC - 27.3

RDW-CV 24.5

smear- microcytic hypochromic with leucopenia and thrombocytopenia

28/02/2023

HAEMOGLOBIN- 8.0 gm/dl

TOTAL COUNT - 1660 cells/cumm

lymphocytes -  41%

monocytes - 12%

pcv - 28.5 

MCV - 78.3

MCHC - 26.1

RDW-CV 24.6

smear- microcytic hypochromic with leucopenia and thrombocytopenia

1/03/2023

HAEMOGLOBIN- 8.9 gm/dl

TOTAL COUNT - 2000 cells/cumm

pcv - 32.4

MCV - 78.6

MCHC - 27.5

RDW-CV 25.2

smear- microcytic hypochromi with leucopenia and thrombocytopenia

2/03/203

HAEMOGLOBIN- 8.2 gm/dl

TOTAL COUNT - 1800 cells/cumm

lymphocytes - 41%

pcv - 29.3

MCV - 78.8

MCHC - 28.0

RDW-CV 24.6

smear- microcytic hypochromic with leucopenia and thrombocytopenia

4/03/2023

HAEMOGLOBIN- 8.7 gm/dl

TOTAL COUNT - 2130 cells/cumm

pcv - 30.0

MCV - 789     

MCHC - 28.6

RDW-CV 24.6

smear- Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia

7/03/2023

HAEMOGLOBIN- 9.2 gm/dl

TOTAL COUNT - 2000 cells/cumm

monocytes - 13%

pcv - 33.4

MCV - 82.1

MCHC - 27.5

RDW-CV 24.5

smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia 

9/03/2023

HAEMOGLOBIN- 9.8 gm/dl

TOTAL COUNT - 2600 cells/cumm

pcv - 34.3

MCV - 80     

MCHC - 28.6

RDW-CV 24.5

smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia

12/03/2023

HAEMOGLOBIN- 8.8 gm/dl

TOTAL COUNT - 2000 cells/cumulative

lymphocytes - 42%

pcv - 30.1

MCV - 80.3

MCH - 23.5

MCHC - 29.5

RDW-CV 22.5

RBC 3.75 millions/cumm

smear-  Anisocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia

13/03/2023

HAEMOGLOBIN- 8.7 gm/dl

TOTAL COUNT - 2000 cells/cumm

pcv - 29.8

MCV - 80.5

MCH - 23.5

MCHC - 29.5

RDW-CV 22.5

RBC - 3.70millipns /cum

smear-  Ansocytosis with normocytes microcytes tear drops pencil forms and macrocytes

impressions -Pancytopenia

Other investigations 

APTT Result- 41s

BLOOD UREA- 26 mg/dl
BLEEDING AND CLOOTING TIME

bleeding time - 2min

clotting time -4min

BLOOD GROUPING AND RH TYPE-B positive

PROTHROMBINE TIM- 2.0sec

SERUM CREATININE - 0.6 mg/dl

HIV - non reactive

Anti HCV antibodies -non reactive

 

ECG

USG

CT

                BONE MARROW ASPIRATION 

BONE MARROW BIOPSY

 

  

Diagnosis: Splenomegaly with pancytopenia. 

TREATMENT 

• inj. Taxim 1g OD 

• inj. Pan 40g OD 

• inj. Zofer OD 

• tab livogen 150mg PO/OD 

• tab ultracet 500mg PO/TID 

• tab mvt PO/OD

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short case

CHEIF COMPLAINTS :-

A 79 year old male was brought to the OPD with cheif complaints of cough since 20 days ,C/o altered sensorium since 3 days, difficulty in swallowing since 1 month and fever since 10 days

HOPI:

Patient was apparently asymptomatic 20days back then  he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. Difficulty in swallowing.

H/o cough on intake of liquids.

 H/o change of voice since 20 days, insidious, hoarse in character and 

 SLURRING OF SPEECH +present

No h/o difficulty in breathing, breathlessness, hemoptysis

 Fever since 10 days -high grade. O/e Chills and rigors + (38 spikes).

N/h/o vomiting, chest pain, loose stools.

7 YEARS BACK:(2016)

He developed head ache at around afternoon 2pm and followed by vomtings and left hand itching and weakness.

PATIENT  is awake on that night due to left hand weakness and itching

NEXT DAY 

MORNING they took him to hospital 

Patient can lift his hand 

But unable to hold objects

AFTER 3 DAYS

PATIENT became left sided hemiplegia.

MRI REPORT- 3 INFARCTS

Patient stayed for 40 days in hospital and there was no improvement and discharged.

He took liquids for 3months because patient is unable to eat solid foods.then he slowing started eating solid foods.

AFTER 1 YEAR (2017):

vomitings 

Fever 

Shivering  for 3 days

 

Diagnosed with urinary tract infection 

Took treatment (antibiotics) for 5 days and it resolved

AFTER 3 YEARS:(2020)

Cough for 2days 

Fever on 2nd day

Diagnosed with covid

He got COVID for 1st time and resolved

After 1 year(2021)

 

He was Diagnosed with COVID for 2nd time and resolved 

1 YEARS back (2022)

He got seizures for 5min and they took him to the hospital.

He got Typhoid fever 2times 

1st time resolved in 7days

2nd time resolved in 9 days

79 Year old male who is a father of 4 children ( 2 sons and 2 daughters)..was used to run shop ( kirana shop) for about 18 years.He stopped looking after his shop from 2006 and he was looked after by his son's.

He was non alcoholic,non smoker.

10 years back , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication.and after 1 year ,with regular check up he was found to be Hypertensive and started on antihypertensive medication.

From 7 years onwards , patient was bedridden with foleys ( changed every 15 days ) and physiotherapy was done by his attenders daily, but there was no such improvement

PAST HISTORY  

 Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications I.e tab TELMA AM 40mg po/od. Tab zoryl mv , po/od

PERSONAL HISTORY 

Appetite lost, 

Mixed diet

Bowel- constipated, 

Bladder regular 

No known allergies and Addictions.

 i.e non alcoholic and non smoker

Family History- no significant family history 

Treatment history   

 

•Tab TELMA AM 40mg po/od since past 10years

 •Tab zoryl mv , po/od

•Tab levipil 500mg since 2 years

• thyronorm 25mcg. Since5 years

GENERAL EXAMINATION 

On examination patient  is arousable but not oriented.

Pt not cooperative mostly. 

-PALLOR:PRESENT

NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS ON ADMISSION 

PR-90 BPM

BP- 140/80MM HG

RR- 22 CPM

SPO2- 98% AT RA

GRBS - 183mg/dl

SYSTEMIC EXAMINATION:

Respiratory :-

Inspection :  respiratory movements equal on both sides

Trachea central

palpation : apical impulse in left  5th  intercostal space 

Auscultation : normal vesicular breath sounds

Percussion- BAE+

CNS

PATIENT is  unconscious incoherent uncooperative

HIGHER MENTAL FUNCTIONS- cannot be elecited

Speech 

Behaviour

Memory

Intelligence

Lobar functions

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

NO SIGNS OF MENINGEAL IRRITATION,

CRANIAL NERVES 

 

1. CN
Sence of Smell - N

2. CN
visual acuity -  decreased on left side

3,4,6 CN
EOM movement - could not perform 
Pupil size - 2, 3 mm
Direct light reflex/consensual light reflex/accommodation reflex - present, present
Ptosis - absent, absent
Nystagmus - absent, absent

5 CN
Sensory over face & buccal mucosa - N, N
Motor - masseter, Temporalis, pterigoids - N, N
Reflexes - Corneal,Conjunctival - N, N
Jaw jerk -

7 CN 
Motor
Nasolabial fold - equal om both sides
Occipito frontalis - equal om both sides
Orbicularis oculi - equal om both sides
Orbicular oris - equal om both sides
Buccinator - equal om both sides

Sensory:
Taste over anterior two third of tongue - cant be performed

8 CN - could not perform 
Rinnes test
Webers test

9, 10 CN -
Uvula palatal arches movements - N, N
Gag reflex - N
palatal reflex - N

11 CN - could not be elicited 
Trapezius
Sternocleidomastoid

12 CN 
wasting - no
Fasciculations - no
Tongue protrusion to midline - midline

 SENSORY SYSTEM- cannot be elicited 

Spinothalamic  sensation:

Crude touch

Pain  

Temperature

Dorsal column sensation

Fine touch 

Vibration

Propioception

Cortical sensation

Two point discrimination

Tactile localisation

Stereognosis

Graphathesia

MOTOR  EXAMINATION:                   

                           Right              n          left

                       UL. LL.                           UL. LL

   BULK        Normal                            Reduced                            

   TONE        Normal                            Hypotonia

   POWER Could not be elicited

SUPERFICIAL REFLEXS 

plantar reflex  

Left side babinski sign positive

DEEP REFLEXES: 

BICEPS, TRICEPS, SUPINATOR, KNEE ANKLE - abnormal

CEREBELLAR  EXAMINATION cannot be elicited

SIGNS OF MENINGEAL IRRITATION: absent

GAIT: patient unable to walk

CVS

ASCULTATION: S1S2 +,NO MURMURS

P/A

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS

AUSCULTATION: no bowel sounds heard

bed sores

C/o asymptomatic lesions all over the body since 2 months

H/o application of unknown topical medications used

O/e multiple hyperpigmented Macclesfield present all over the body with scaly lesions over the upper back

•Diffuse xerosis present

• single ulcer of size 1.5x1.5 cms (approx) over the back.

Diagnosis SENILE XEROSIS + post inflammatory hyperpigmentation.

INVESTIGATIONS:

 Anti HCV antibodies rapid -nonreactive

Blood urea -30mg/dl

HBA1C-6.7%

HbsAg rapid - negative

HIV 1/2 RAPID TEST - NON REACTIVE

TOTAL BILIRUBIN -0.81mg/dl(normal-0 to 1mg/dl)

Direct bilirubin-0.17mg/dl(0 to 0.2mg /dl)

Serum creatinine -0.9 mg/dl (0.8 to 1.3 mg /dl)

ABG

Ph 7.51

PCO2 29.5mmhg

Po2 67.5 mmhg

Electrolyte

Sodium 135meq/l

Potassium 3.5 meq/l

Chloride 98meq/l

Calcium -1.06 mmol/l

PROVISIONAL DIAGNOSIS 

Recurrent CVA with hypertension, type 2 DM, seizures disorder 

TREATMENT 

1) TAB ECOSPRIN 150 mg RT/OD

 

2) TAB CLOPIDOGREL 75 MG RT/OD 

3) TAB ATORVAS 20 MG RT/OD

4) NEBULISATION - 3% NS ,

                                 MUCUMZY 8th hourly 

5) CHEST PHYSIOTHERAPY.

6) RT FEEDS 100 ML WATER 2nd HRLY

   50 ML Milk 2nd HRLY.

7) TAB. THYRONORM 25MCG RT/OD

8) TAB. LEVIPIL