1801006171 CASE PRESENTATION

LONG CASE 

23 year old female who has a general store came to gm opd with 

 

Chief complaints :

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

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 9 years back then she started developing pain in left hypochondrium which is insidious in onset intermittent & dragging type .she had visited local unregistered medical practitioner with complaints of pain and recieved painkillers. 

since last one year she is having 2-3 episodes of pain every month lasting for an hour or more 

•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) . change in colour of stool is observed after intake of tablets 

H/o shortness of breath since 1 year Grade 3(dyspnoea on walking some distance)

H/o easy fatiguability

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 H/o weight loss

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  

Pallor present 

•icterus, cyanosis, clubbing, lymphadenopathy, pedal edema  are absent 

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

No visible pulsations,peristalsis, dilated veins 

Visible swelling in the left hypochondrium , about 3x4cm in size, ovoid in shape,  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( palpation done by conventional method)

https://youtube.com/shorts/_vXhQ_6T5FE?feature=share

No palpable liver 

PERCUSSION:

liver span -11 cm (normal 6-12)

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 raised 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 : normal 

B/L symmetrical , 

Both sides moving equally with respiration 

No scars, sinuses, engorged veins, pulsations

•Palpation

Trachea - central

Expansion of chest is symmetrical.

•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::

SPLENOMEGALY WITH ANEMIA

INVESTIGATIONS :COMPLE BLOOD PICTURE

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

ECG

Ultra sound

Ct abdomen

 bone marrow biopsy 

Final Diagnosis : splenomegaly with pancytopenia

TREATMENT :-

• tab livogen po / od 

  tab.ultracet  po / sos 

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SHORT CASE

A 50 year old male presented to the casualty with weakness of right upper and lower limbs since the morning of 13/3/23 4am. With slurring of speech and deviation of mouth to the left side. 

History of presenting illness 

Patient was apparently asymptomatic 1 month back, he later developed giddiness followed by a fall. He was diagnosed with hypertension( HTN) to which he used medication for 20 days and stopped 10 days ago. 

He was asymptomatic until 17 th March 2023when he noticed weakness in his right upper and lower limbs while going to the washroom.

slurring of speech also seen

 Symptoms were sudden in onset and quick in progression.  

There is history of (H/O) trauma

Upper limb- Patient has difficulty in combing hair, difficulty in buttoning and unbuttoning.

Lower limb- not able to stand due to swaying towards right side

There is no H/O difficulty in swallowing, giddiness, headaches, nausea, vomiting, drug intake, chest pain, drug intake, tingling sensation of effected limbs. 

no history of difficulty in closing eyes , lips, able to sense taste and able to move neck and tongue

Past history 

30 years ago sustained a fracture in the right elbow.

Diagnosed with HTN one month back.

Patient started using medication for hypertension for 20days and stopped for next 10days.

No H/O diabetes mellitus, epilepsy, tuberculosis, coronary artery disease, thyroidal illness, HIV, malignancy, fever, drug intake

Personal history 

Diet- mixed

Appetite- normal

Bowel and bladder- regular

Sleep- adequate

Addictions- The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days.

He consumes alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago after the death of his daughter’s husband.he drinks around 90 ml per day

Family history-

 no relevant family history 

Treatment history

Patient took treatment for hyper tension

General examination 

Patient is examined after taking consent

Patient is examined in a well lit room

Consent of the patient was taken 

Patient is conscious, coherent and cooperative 

Well built and nourished

pallor: absent 

Icterus: absent

Cyanosis: absent

Clubbing:absent

Lymphadenopathy: absent 

Edema: absent 

Temperature: 98°F  

Pulse:60 beats/ minute 

Blood pressure: 140/80mmHg 

Respiratory rate: 14 cycles/minute 

No involuntary movements 

No abnormal neck swellings 

No neck stiffness present

Systemic examination

CENTRAL NERVOUS SYSTEM

Higher mental functions

Patient is conscious 

Oriented to time,place and person

Well dressed, well behaved and in a good mood

Speech slightly slurred, language understandable 

Memory is intact 

Cranial nerves

Olfactory nerve: smells perceived 

Optic nerve: counting fingers 6m

III, IV, VI: ocular motility normal, pupillary reflexes normal

Trigeminal nerve: jaw jerk present, corneal reflexes present

Facial nerve: mouth deviated to the left side

Vestibulocochlear nerve: normal sensory hearing

IX, X: no difficulty in swallowing

Accessory nerve: neck movements normal place and person

Motor system

No muscle wasting

Normal muscle tone

Power: upper limbs- right 3/5. Left-5/5

              Lower limbs- right 0/5. Left- 5/5

Reflexes.                             Right.      Left

             Supinator-                3.               3

              Biceps.                  3.                 3

              Triceps.                 3.                 3

              Knee.                      3.                3

              Ankle             Extensor       Extensor

Coordination

        Finger to nose- present on right side

        Dysdiadochokinasea- present on right side

        Knee to hell- uncoordinated on the right side

Sensation- pain, temperature, proprioseption, vibration felt equally on both sides

Gait- unable to walk without support, dragging legs

Rombergs test- couldn’t be elicited

CARDIOVASCULAR SYSTEM. 

*Inspection- normal shape, bilaterally symmetrical, no percardial bulge, no engorged veins

*palpation- apical beat felt at 5th inter coastal space, no additional pulsation felt, no thrills felt

*percussion- heart borders noted

*auscultation- S1 and S2 heard. No additional heart murmurs

ABDOMEN

*inspection- flat abdomen with no distension, no engorged veins visible, skin over abdomen normal, umbilicus central, hernial orifices normal, external genital normal.  

*palpation- no tenderness present, temperature to touch normal, no abnormal swellings. 

*percussion- tympanic sound with dullness over solid organs

*auscultation- bowel sounds heard.

RESPIRATORY SYSTEM 

*inspection-chest normal shape and bilaterally symmetrical

*palpation-trachea midline, chest movements symmetrical, tactile and vocal fremitus felt

*percussion- no dullness present bilaterally 

*auscultation: Normal vesicular breath sounds heard, no added sounds. 

Diagnosis: Cerebrovascular accidentwith right hemiparesis. 

Investigations:

Haemogram:

Haemoglibin 13.4

Total lecucocyte count 7,800

Red blood cells 4.45

Platelets- 3.01

Complete urine examination 

Pale yellow clear

Acidic

Trace albumins

Pus cells 3-4

Epithelial cells 2-3

Sugars nil

Thyroid function tests 

T3 0.75

T4 8

TSH 2.18

 

Chest x ray

Ct scan head

Mri of brain

Renal function test

Urea: 19mg/dl

Serum. Creatinine: 1.1mg/dl

S. Na+: 141 mEq/L

S. K+:. 3.7 mEq/L

S. Cl-: 1.02 mmol/L

FASTING BLOOD SUGAR: 114mg/dl

Diagnosis

CEREBROVASCULAR ACCIDENT WITH RIGHT HEMIPARESIS WITH ACUTE INFARCT IN POSTERIOR LIMB OF LEFT INTERNAL CAPSULE

K/C/O HTN SINCE 1 MONTH

Treatment: 

1. TAB. ECOSPRIN 150 MG PO/STAT

2. TAB. CLOPITAB 150 MG PO/STAT

3. TAB. ATORVAS 80 MG PO/STAT

4. PHYSIOTHERAPY OF UPPER AND LOWER LIMB

5. I/O CHARTING

6. VITALS MONITORING

7. INJ. OPTINEURON IN 1 AMP IN 500ML NS IV/OD