1801006138 CASE PRESENTATION
long case
77 year old male daily wage laborer by occupation resident of narayanapuram came to opd with chief complaints of
-abdominal distension since 3 days
History of presenting illness:-
Patient was apparently a symptomatic until 3 days ago then he had complaints of sudden onset of abdominal distention accompined with twisting type of pain; Dyspnea, constipation decreased urine output, painful defecation aggravated after having food
No complaints of fever headache giddiness
No complaints of bilateral pedal edema
No complaints of burning micturition
Past illness:-
History of analgesic abuse for knee pain
History of empyema 15years ago
PERSONAL HISTORY: -
Diet - mixed
Appetite- normal
Sleep - normal
Bowel - regular
Bladder - decreased output and burning micturition
Allergies- none
Addictions- Beedi 4/ day
Toddy/ every 3 days
FAMILY HISTORY:Not significant
GENERAL EXAMINATION:
Patient is conscious, coherent and co-operative.
Examined in a well lit room.
Moderately built and nourished
Vitals
Temperature:-afebrile
Respiratory rate:- 16cpm
Pulse rate :-74bpm
BP:- 120/80mm Hg
Systemic examination
Cardiovascular system :-
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
Apical impulse and pulsations cannot be appreciated
PALPATION:
Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.
No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders percussed.
AUSCULTATION:
S1 and S2 heard , no added thrills and murmurs heard.
Respiratory system
INSPECTION:
Chest is bilaterally symmetrical
Trachea – midline in position.
Apical Impulse is not appreciated
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
Trachea – midline in position.
Apical impulse is felt on the left 5th intercoastal space.
Chest is moving equally on respiration on both sides
Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Upper/mid/lower interscapular were all RESONANT.
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard
Abdominal examination:-
Inspection:-
Shape of abdomen:-distended
Umblicus:- normal
Movements of abdominal wall :- moves with respiration
Skin is smooth and shiny
No scars sinuses
distended veins :- present
Palpation:-
Local rise of temperature present
Tenderness present in RT hypochondriac region
Tense abdomen
Guarding absent
Rigidity absent
Fluid thrill absent
Liver not felt
Spleen not felt
Kidney not felt
Lymph nodes not palpable
Percussion:-
Liverspan :- not detectable
Fluid thrill:-not felt
Shifting dullness:- present
Tympanic note is heard on midline and dull note is heard on flanks in supine position
Auscultation:-
Bowel sounds are decreased
CNS examination:- No neurological deficits seen
Provisional diagnosis :-
Ascites under evaluation
Investigations:-
Serology:-
Hiv-negative
Hcv- negative
HBsAg- negative
Outside USG:-
1. Liver altered parenchymal ecotextur
2. Cholecystitis
3. Bilateral grade 2 rpd changes with renal cortical cysts
4. Moderate ascites
Treatment :-
1.T dolo650mg/po/tid
2.therapeutic ascitic tap was done
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short case
30 year old female came to the op with
*Chief complaints of:-
•Bilateral joint pains in upper and lower limbs(knees, hip, ankle, shoulder, elbow, wrist, including small joints) since 10 months.
•Itchy lesions over the face,upper aspect of the chest, neck and back of the neck and upper trunk with dark coloured lesions over the knuckles since 10 months.
•Generalised weakness since 10 months - Inability to comb the hair, difficulty in walking and inability to sit down.
History Of present illness:-
•Patient was apparently asymptomatic 10 months back after which she developed bilateral symmetrical multiple joint pains involving all joints and it's severe in the knees which was insidious in onset, gradually progressive, aggravated on walking and relieved on medication i.e.tab.HYDROXYCHLOROQUINE 200 mg
•Associated with morning stiffness.
•Around the same time she developed itching over neck and upper chest area.The area was initially red and turned black due to itching.
•H/o Dark coloured skin lesions over the knuckles since 10 months
•H/o photosensitivity present (Itching increases on sun exposure)
•H/o Alopecia since 10 months. It was gradually progressive leading to severe hair loss over the past 10 months. Associated with thinning of hair.
•H/o bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands.
•H/o generalised weakness since 10 months.
•H/o Dfficulty in walking and difficulty to sit down.
•H/o distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, dressing and undressing, combing of hair.
•H/o proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.
•H/o weight loss of 4-5 kgs over the last 10 months.
•H/o vaginal discharge since 7-8 months. It was initially curdy white discharge which later changed to watery discharge. Associated with itching.
•H/o Genital ulcers on and off since 7 months.
•Dyspnea on exertion (NYHA- 3),gradually progressive since 4-5 months.
•No h/o fever, cold, cough.
Past History:-
•No similar complaints in the past.
•Not a k/c/o DM, HTN,TB, epilepsy, Asthma, CAD.
*Menstrual History:-
•Age of menarche:-11 years
•Duration of cycle :- 3/28 days
•Regular cycle with no pains and no clots.
*Marital History:-
•Age at marriage:19years
•Non consanguinous marriage
*Personal History:-
•Diet- Mixed
•Appetite- Decreased
•Sleep- Inadequate since 10 months
•Bowel and bladder habits- Regular
•No addictions
•No known drug allergies
Family History:- •Not significant
*General Examination:-
•Patient is conscious, coherent and cooperative.Well Oriented to time, place and person.
•She is moderately built and moderately nourished.
•Pallor- Present
•cyanosis-Absent
•clubbing-Absent
•lymphadenopathy-Absent
•Pedal Edema- Present
On Examination:-
•Diffuse mottled erythematous hyperpigmentation (Heliotrope rash) noted on B/L cheeks, nose(bridge) involving nasolabial folds, ears, neck extending onto upper chest and back forming a ‘V’ on anterior chest (Shawl sign) and (V sign).
•Mottled erythematous lesions on the palms
Vitals:-
•Temperature- Afebrile
•BP- 130/80 mm Hg
•PR- 102 bpm
•RR- 14 cpm
•SpO2- 99% @ RA
Systemic Examination:-
CENTRAL NERVOUS SYSTEM EXAMINATION.
HIGHER MENTAL FUNCTIONS:
Patient is Conscious, well oriented to time, place and person.
All cranial nerves - intact
Motor system
Right. Left
BULK
Upper limbs. N. N
Lower limbs. N. N
TONE
Upper limbs. N. N
Lower limbs. N. N
POWER
Upper limbs. 5/5. 5/5
Lower limbs 5/5. 5/5
Superficial reflexes and deep reflexes are present , normal
Gait is normal
No involuntary movements
Sensory system - all sensations ( pain, touch, temperature, position) are well appreciated
CARDIOVASCULAR SYSTEM
INSPECTION:
Chest wall - bilaterally symmetrical
No dilated veins, scars, sinuses
PALPATION:
Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.
No parasternal heave, thrills felt.
PERCUSSION:
Right and left heart borders percussed.
AUSCULTATION:
S1 and S2 heard , no added thrills and murmurs heard.
RESPIRATORY SYSTEM:-
INSPECTION:
Chest is bilaterally symmetrical
Trachea – midline in position.
Chest is moving normally with respiration.
No dilated veins, scars, sinuses.
PALPATION:
Trachea – midline in position.
Apical impulse is felt on the left 5th intercoastal space.
Chest is moving equally on respiration on both sides
Tactile Vocal fremitus - appreciated
PERCUSSION:
The following areas were percussed on either sides-
Supraclavicular
Infraclavicular
Mammary
Axillary
Infraaxillary
Suprascapular
Infrascapular
Upper/mid/lower interscapular were all resonant
AUSCULTATION:
Normal vesicular breath sounds heard
No adventitious sounds heard
ABDOMEN EXAMINATION
INSPECTION:
Shape – normal
Flanks – free
Umbilicus –central in position , inverted.
All quadrants of abdomen are moving with respiration.
No dilated veins, hernial orifices , sinuses
No visible pulsations
PALPATION:
Soft, non tender
Spleen liver kidney not palpable
PERCUSSION:
There is no fluid thrill , shifting dullness
AUSCULTATION:Bowel sounds are heard
Provisional diagnosis:-
Dermatomyositis with vaginal candidiasis
Investigations:-
Haemogram
Hb-10.6
Tlc-3500
Neutrophils-68
Lymphocytes-20
Eosinophils-2
Basophils-0
Monocytes -10
Pcv-32
Mcv-80.8
Mch-26.8
Mchc-33.1
Platelet count-1.73
Impression:-Normocytic normochromic anemia with mild leucopenia
Complete urine :---
Colour-pale yellow
Appearance-clear
Reaction-acidic
Sp gravity-1.010
Albumin-nil
Sugar-nil
Bilepigments-nil
Bile salts-nil
Pus cells -2-4
Epithelial cells-1-2
Others-nil
Serum creatinine
Serum creatinine -0.6
Random blood sugar
Rbs:-118mg/dl
Serum electrolytes
Sodium -139
Potassium -3.9
Chlorine-102
Esr -70
Esr is elevated
Serology- negative
RA- negative
Crp- negative
Treatment:-
1.Tab.Fluconazole 150mg/PO/stat
2.Candid cream L/A
3.Tab pan 40 mg PO/OD
4.Tab Ultracet 1/2 tab/PO/Q.I.D
5.Syrup.Grilinctus BM 10ml/PO/T.I.D
6.Syrup.Mucaine Gel 10ml/PO/T.I.D
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