Case report samples done by previous students for current batch guidance

CNS LONG CASE: Informant: Patient A 38 year old male, a resident of chandanapally, nalgonda district came to the hospital with complaints of difficulty in walking since 8 years Chief complaints: difficulty in walking since 8 years (2014 March) Feeling weak during walking since 7 years (2015 January) History of present Illness: The patient had difficulty while walking, while getting up from chair without support, but gets up from chair with support, difficulty in squatting, difficulty in sitting on floor, difficulty in getting up without support from floor. Initially he had difficulty in going uphill but since 3 years he was complaining of difficulty in walking on level ground also. Uphill: steps are difficult Downhill: comparatively easier steps than uphill Difficulty in running The patient did not have any difficulty in wearing chappals, holding chappals. He did not have any problem in removing chappals. However he complained that it was easier to walk without chappals since there was lesser weight lifting needed. After having these symptoms for 8-9 months the patient went to the hospital for checkup and was given medication for which there is no record of with the patient. According to the patient, he was not on regular medication and the medication didn’t improve his symptoms. Overtime, he had feeling of heaviness of upperlimb while lifting his hand over the head which progressed over time to having difficulty in lifting his arm to shake hands , eat his food and take his brush from the cupboard. He complains that he has to give an increased initial try for him to lift his hand. After initiating combing, he doesn’t have any difficulty in combing the hair. He feels that it is difficult to move the brush in his mouth. Difficulty in lifting food to mouth. Not associated with falling of food particles and not associated with falling of food from mouth. No difficulty in chewing food after putting food in the mouth. Difficulty in bathing with mug. Washes more on the right side with difficulty in washing on the left side. Difficulty in getting from bed without support since 1 year. No difficulty in turning to sides on bed. No difficulty in eating, chewing, closing eyes, swallowing food, whistling, shouting, winking. Complaints of intermittent spasm of muscles after prolonged sitting. Complaints of muscle cramps. No complaint of difficulty in feeling things he touches. No difficulty in feeling chappals sensation. As he walks without chappals he is used to pain while walking and says that his feet are more prone to injuries. He doesn’t have any difficulty in feeling pain when there is an injury. He doesn’t have ulcerations or abnormal sensations anywhere on the body. He is able to feel the temperature of the water while bathing. The patient doesn’t have any complaints of blurring of vision, difficulty in smell, double vision, vision difficulties, no loss of area of vision, no difficulty in swallowing and tasting, normal facial expressions, no difficulty in hearing sounds of low intensity or high intensity. The patient complains the he feels bad that he lost his job as a watchman because of the difficulty in working after onset of difficulty in walking and weakness. But he does not have history of acting out. He feels bad about not earning money but he tells that he got used to the complaints over time. No history of headaches, nausea, vomiting, involuntary movements. The patient does not complain of loss of balance or falls but he tells that sometimes while getting up from a chair, he doesn’t have the power to get up and sits back. No complaints of urgency, hesitancy, increase in frequency during night, difficult in initiating urination, burning during urination. He had complaints in difficulty in passing stools intermittently for which he takes more water or a tablet and the symptom subsides. He didn’t contact doctor for the complaint as it was intermittent and reduced with more intake of water and bananas. No history of fever, sleep disturbances, no history of injury to feet. Birth history: The patient had history of second degree consanguinity and was born at home with the help of dai and apparently without any problem after birth in his words. He walked without support at 3 years and started talking in sentences at 7 years of age. He has stuttering while talking but doesn’t have a problem in formation of sentence, language or difficulty in pronunciation of words. He says that he stutters more when there is lack of sleep. Family history: No history of similar complaints in the family. His mother and father died in an accident and he is not married due to his stuttering problem at first and weakness later. Personal history: The patient was a smoker previous for 6 months in 2012 but stopped later. He is an occasional alcoholic and drinks one glass of toddy during festivals. No sleep and appetite abnormalities. No bowel and bladder abnormalities. Past history: The patient had a history of fall from cycle in 2012 after which he had a fracture in the left wrist but did not go to the hospital and took Ayurveda treatment. Now there is a deformity in the left wrist and reduced range of movement with difficulty in using the hand. No known history of diabetes, hypertension, bronchial asthma, allergies, tuberculosis, jaundice or prolonged hospital stay. Drug history: No known usage of drugs for more than 1 week, no history of usage of injections in the hospitals. No known history of any drug allergies. Summary: Based on the above history the patient had slowly progressive weakness of the lower limbs more proximal than the distal and overtime it progressed to the upper limbs with more proximal weakness than distal and he developed weakness in the trunk overtime. He doesn’t have spasticity or rigidity in the muscles. He doesn’t have sensory complaints. He complains weakness more in the lower limbs than upper limbs. He has no cerebellar, autonomic system, cranial nerves or higher mental function abnormalities. The patient had history of consanguinity, delayed milestones and history of malunited left wrist fracture. General physical examination: The patient is conscious, coherent, comfortable, cooperative. No distress or features of pain. The patient doesn’t appear pale. There is no icterus, clubbing, cyanosis, pedal edema, generalised lymphadenopathy on examination. Weight- 54 kgs Height- 162 cms BMI- 20.57 kg/m2 BP- 110/70mm Hg Hair, nails, skin and spine- normal Systemic examination: Neurological examination: Higher mental functions: The patient is conscious, appears comfortable, language and behaviour appears normal. Orientation to time place and person normal. Mood and emotional status appears normal. Memory: immediate, recent and remote memory tested- normal. Mini mental status examination score- orientation-5/5 Registration-3/3 Attention and calculation- 2/5 Recall- 3/3 Total score- 25/30 No illusions or hallucinations Speech: normal verbal output, fluency, repetition, naming, reading, writing. Appearance- no tics, tremors, myoclonus, involuntary or voluntary movements Motor examination: Bulk: upper limb- right upper limb- 24.5 cms above elbow, 22cms below elbow Left upper limb- 23.5cms above elbow, 22 cms below elbow Lower limb- right lower limb- 43 cms above knee, 32 cms below knee Left lower limb- 43 cms above knee, 32 cms below knee Tone: hypotonic in right upper limb and lower limb, hypotonic in left upper limb and lower limb. Power: Right Left Upper limb- distal flexors- -4/5 -4/5 Proximal flexors 3/5 3/5 Hand muscles- extensor pollicis longus- 3/5 on both sides, all the others are 4/5 power Trunk muscles- 3/5 on both sides Lowerlimb- hip muscles- iliopsoas- 3/5 on both sides Adductor femoris- 3/5 on both sides Hamstring muscles- 3/5 on both sides Gastrocnemius muscles- -4/5 on both sides Extensor hallucis longus- -4/5 on both sides Coordination- normal coordination of movements Reflexes: biceps- reduced but present + on both sides Supinator- + on both sides Triceps- + on both sides Ankle - + on both sides Plantar- flexor response on both sides Sensory examination: touch- normal on both sides Temperature- both hot and cold sensation normal on both sides Vibration- normal on both sides Joint position- 5/6 times on right side, 6/6 times on left side Cerebellar examination: Hypotonia- present No rebound phenomenon Finger nose test- normal Finger finger test- normal Heel shin test- normal No past pointing, intentional tremor or gait abnormalities. Gait: normal stride, Normal width, normal turning, The patient is not able to walk on toes. Cranial nerves: normal smell and vision Pupillary light reflex- normal, accommodation reflex - normal, normal manual perimetry, normal primary eye movements, normal sensations over the face, normal glabellar tap, corneal reflex, conjunctival reflex and jaw jerk, normal facial expressions, normal taste sensations all over tongue, no deviation of facial muscles or tongue muscles. Normal shrugging, head turn against pressure. Autonomic system: no bowel bladder abnormalities, no abnormal sweating, no orthostatic hypotension, no postprandial syncopal attacks, no history of falls with loss of consciousness. Intracranial pressure: no signs of raised intracranial pressure Skull and spine: normal Cardiovascular system: Inspection: normal on inspection, no visible pulsation, apex beat not visualised. No visible lesions on chest. Equal and symmetrical chest movements with respiration. Palpation: apex beat felt on the left 5th intercostal space 1cm medial to mid clavicular line. All the findings of inspection are confirmed. Percussion- all the borders of heart normal on percussion Auscultation- s1, s2 heard. No added sounds, no murmurs heard, normal split heard in s2. Respiratory system: Inspection- normal on inspection, no visible pulsation, apex beat not visualised. No visible lesions on chest. Equal and symmetrical chest movements with respiration. Palpitation- apex beat felt on the left 5th intercostal space 1cm medial to mid clavicular line. All the findings of inspection are confirmed. Percussion- no abnormal findings on percussion Auscultation- normal vesicular breath sounds heard equally on both sides Abdominal examination: Inspection- normal on inspection, no visible pulsations, no visible lesions on abdomen. Palpation- no organomegaly Percussion- Auscultation- bowel sounds heard at normal frequency Ecg- Chest X-ray- normal Serum creatine phoshokinase- 780 IU/ lit Nerve conduction study- normal Elctromyography- reduced amplitude with polyphasic motor response- suggests myopathy Muscle biopsy report- Final diagnosis: Based on the above history, examination and findings, the most probable diagnosis is progressing symmetrical proximal muscular dystrophy involving both lower limbs and upper limbs without any known family history or heart involvement so most probably could be beckers or limb girdle muscular dystrophy based on the above mentioned findings. Differential diagnosis- the other possible diagnosis could be chronic inflammatory demyelination syndrome but it is predominantly sensory and in this case sensory findings are minimal. Other possible diagnosis could be proximal motor neuropathy or neuronopathy but there is no history of diabetes or involvement of muscles of neck, swallowing. Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006009-case-presentations.html SHORT CASE: History given by patient and her husband and is reliable A 45year old female, right handed ,housewife, resident of Nalgonda presented with chief complaints of -headache since 2years -Bilateral Knee,ankle,elbow joint pains since 6months -weakness of right upper and lower limbs since 30days -deviation of mouth to left since 30days -Double vision since 10days History of present illness: Patient was apparently alright 2years back ,then she developed headache-acute in onset, Intermittent ,throbbing type,diffuse and bilateral .Not associated with nausea ,vomitings,photophobia,phonophobia, laceration,blurring of vision. Complaints of bilateral Knee,ankle,elbow joint pains since 6months -not associated with fever,restriction of movements,early morning stiffness,swelling of joints -relieved by taking analgesics and aggrevated on exertion. Complaints of weakness of right upper and lower limb since 1month -acute in onset and gradually progressive - initially she had mild symptoms ,that gradually progressed over 1 month to current status .Initially she used to walk alone till the bathroom With some difficulty ,later patient found difficulty in walking without support and patient felt more giddiness while walking. Complaints of mild deviation of mouth to left side , not associated with drooling of saliva Complaints of Double vision since 1month- intermittent ,horizontal and binocular ,no history of black spots,colored halos,floaters,blurring of vision. Able to perceive taste sensation. Past history: Non Diabetic,Non Hypertensive, No history of Asthma,CAD,Epilepsy. She underwent hysterectomy 20 years back. Family history : She was married at the age of 18 years ,3rd degree consanguinity 1 st child- spontaneous vaginal delivery - 25 yrs old 2 nd child-vaginal delivery, died at 1 month of age due to unknown reason 3rd child - died at the age of 21 due to kidney failure No history of similar complaints in family. Personal history: Mixed diet Sleep adequate Bowel and Bladder habits regular No addictions Socio economic status - lower middle class Menstrual history: Age of menarche : 15 years ,regular cycles-5/30 ,no dysmenorrhoea Drug history : Patient was on T.ECOSPIRIN 75mg/PO/OD T.ATORVAS 20mg/PO/HS Summary:A 45 year old right handed female patient, who is non hypertensive and non Diabetic with no addictions presented with headache since 2years and progressive weakness of right upper and lower limb since 1month and double vision double since 10days. Differential Diagnosis: 1.Cerebro vascular accident involving mid brain and Pons 2. Basilar artery occlusion 3.Demyelinating disorders General examination: Pt conscious,coherent ,cooperative oriented to time ,place and person . Moderately built and nourished . BMI: 24.6kg/m² Vitals : Pulse : 82beats per minute , regular, normal volume ,vessel wall normal ,no radio-radial delay ,no radio femoral delay, all peripheral pulses felt. Blood pressure: right arm -120/80mmHg ,supine position Left arm -120/80mmHg ,supine position Right leg - 130/80mmHg Left leg -130/80mmHg Respiratory rate- 16cycles per minute, thoracoabdominal ,no usage of accessory muscles. Temperature - 98.2F SpO2-98% at room air JVP - not elevated Physical examination: No Pallor, icterus, cyanosis, clubbing, generalized lymphadenopathy, edema. Systemic examination: Patient is conscious,coherent and cooperative Right handed person MMSE - 30/30 Nystagmus -absent Speech - spontaneous with intact naming ,repetition,fluency. Spine -normal Cranium -normal gait -hemiplegic gait Cranial nerves - right. Left 1.Sense of smell - normal. Normal 2.Visual acuity - normal. Normal Field of vision- normal. Normal colour vision. Normal. Normal fundus. Normal. Normal 3,4,6 : extra ocular movements: -restriction in adduction elevation,depression on right side and normal on left side -pupils: Normal size and reacting to light on both sides -direct and consensual light refleces normal in both eyes No Nystagmus no ptosis 5. Sensory : sensations over face normal on both sides Motor - massager,temporarily, pterygoids normal 7.motor : loss of nasolabial fold on right . Orbicularis ocular, orbicularis Oris ,occipital frontalis, buccinator -normal on both sides Sensory : taste over anterior 2/3rd of tongue normal on both sides 8.rinnes test normal on both sides . Webers test normal on both sides 9.10.uvula , palatal arch movements normal. Gag reflex. - normal Palatial reflex - normal 11.tarpezium and sternocleidomastoid -normal 12. No wasting and fasciculations Tongue protrusion to midline. Motor system examination : 1.Bulk (nutrition): right. Left Inspection. Normal. Normal Measurements :U/L 26/22cm 26/22cm L/L. 46/ 34cm. 46/34cm 2.Tone : U/L hypotonia. Normal L/L. Hyportonia. Normal 3.power: Neck muscles. 5/5. 5/5 upperlimb: Shoulder- -4/5. 5/5 Elbow - -4/5. 5/5 Wrist - -4/5. 5/5 Handgrip- 50% 100% Lower limb: Hip - 3/5. 5/5 Knee- 3/5. 5/5 Ankle - 3/5. 5/5 Trunk muscles- normal. Deep tendon Reflexes - right left Biceps +++ +++ Triceps +++ +++ Supinator ++ ++ Knee. +++ +++ Ankle. +++ +++ Jaw jerk. Present Superficial reflexes - Corneal. + + Conjunctival. + + Pharyngeal. + + Palatal. + + Abdominal. + + Cremastric. + + Plantar. Extensor extensor Sensory system examination: Spinothalamic: right. Left Crude touch - normal. Normal Pain- normal. Normal Temperature- normal. Normal Posterior column Vibration sense- normal Normal Fine touch - normal. Normal Position sense - normal. Normal Cortical senses 2point descrimination- normal. Normal Tactile localization - normal normal Stereognosis - normal. Normal Graphesthesia - normal. Normal Cerebellar examination: right left Finger nose test - normal. Normal Finger nose finger test- normal. normal Disdiadokinesia - no no Heel knee test - normal. normal Tandom walking. - could not be performed Rombergs sign - could not be performed Gait examination- hemiplegic gait Spine examination- normal Peripheral nerves - no nerve thickening,no foot or wrist drop . Here are some videos of her CNS examination Other systems CVS : S1S2 + , No murmers , Apex normal Respiratory system: Normal vesicular breath sounds +, no added breath sounds. GIT : No abnormalities + Provisional Diagnosis : Sudden onset right sided hemiparesis which is gradually progressive , with right UMN type of Facial palsy and 3rd nerve involvement due to demyelinating/inflammatory etiology involving midbrain and Pons . With the given history and examination we evaluated her further MRI BRAIN (Plain and contrast )with Angiogram was done that showed T2 hyperintensities noted along short segment of Cervical cord T2 FLAIR showing hyperintensity right internal capsule T2 FLAIR image showing hyperintensities in midbrain,bilateral thalami T2 weighted Transverse section MRI BRAIN showing hyperintensity involvement of Midbrain sparing Red Nucleus . Carotid Artery Doppler: Soft Plaque in left carotid artery without significant stenosis. ECG 2D echo : normal Chest x-ray PA view: Treatment: 1.Iv methyl prednisolone 1gm /IV was started and continued for 5 days 2.Tab.Ecospirin Av(75/20 mg) /po/OD 3. Supportive treatment After IV Methylprednisolone Patient improved symptomatically And objectively her power improved in upper limbs to 4/5 and lower limbs - initially from 2/5 to 4/5 over period of 2-3 days. This video is taken after Receiving high dose of steriods , Patient was able to walk alone for some distance ,with some difficulty .But there is significant improvement in Power going by objective evidence of muscle power. LUMBAR PUNCTURE : Lumbar puncture was done , and CSF analysis was sent . Colur - colorless Appearance- clear Total counts - 16cells /cumm Lymphocytes-100% Neutrophils - nil CSF glucose -94mg/dl Protein- 79mg/dl Chloride -114mmol/lit High protien and lymphocyte predominant - suggestive of inflammatory process Anti NMO antibody levels : Serum Aquaporin levels were sent and came negative Patient was discharged and continuously followed up. Patient improved symptomatically and is able to walk alone and able to perform her own activities . Review MRI was done to look for any new lesions.Mri showed regression of hyperintense lesions . Discussion: 1.https://academic.oup.com/brain/article/122/11/2171/377380 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC490512/ This shows only few percent of people show Neurologic symptoms prior to systemic manifestations, and most commonly they develop within 6months - 1 year ,( range 6 months -3years ) On the other hand, Ikedat7 stressed that the common neurologic features of neuro- Behqet's syndrome were motor impairment especially bilateral pyramidal signs and that the mental changes mainly consisted of loss of emotional control with relative sparing of intelligence and memory. 2 . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5109654/ We performed a systematic review and meta-analysis of studies on neurosarcoidosis published between 1980 and 2016 We identified 29 articles describing 1088 patients diagnosed between 1965 and 2015. Neurosarcoidosis occurred in 5% of patients with systemic sarcoidosis. Mean age at presentation was 43 years and neurological symptoms were the first clinical manifestation of sarcoidosis in 52%. The most commonly reported feature of neurosarcoidosis was cranial neuropathy in 55%, with the facial and optic nerve most commonly affected, followed by headache in 32%. Pleiocytosis and elevated CSF protein were found in 58 and 63%. MRI of the brain showed abnormalities in 70%. Chest X-ray, chest CT, or gallium-67-scintigraphy showed findings consistent with sarcoidosis in 60%, 70% and 69%, respectively. 3: Isolated neurosarcoidosis presenting as meningitis https://onlinelibrary.wiley.com/doi/full/10.1002/ccr3.1418 The exact etiology of neurosarcoidosis is unknown and multifactorial, involving genetic predisposition and individual and environmental factors Exposure to mildew, musty odors, pesticides, and agricultural employment have been associated with the development of sarcoidosis Clinical manifestations of neurosarcoidosis can be found in 5–20% of cases of systemic sarcoidosis, and these symptoms can be mild or severe 5 (Table 2). About half of patients with neurosarcoidosis can present with neurologic manifestations sooner than systemic sarcoidosis is apparent 5: https://sarcoidosisnews.com/2016/07/19/isolated-neurosarcoidosis-difficult-to-diagnose-but-easy-to-treat/ 6: https://www.hindawi.com/journals/pri/2012/871019/ Articular involvement is characterized by nonerosive and nondeforming arthritis which often presents with monoarticular pattern, although asymmetrical polyarthritis can occur. The articular involvement is usually transient in nature with episodes lasting from a few days to weeks Parenchymal involvement including brainstem involvement, hemispheric manifestations, spinal cord lesions, and meningoencephalitis is seen in the majority of patients (%80) Table 6: Summary of evidence-based algorithmic therapy for Neuro-Behc ̧ et’s disease. 1st line. Corticosteroids 2nd line Azathioprine, cyclophosphamide, Anti-TNF-α, IFN-α 3rd line Methotrexate, Anticoagulation In parenchymal involvement, corticosteroids (100 mg/d or 1 gx 5 days as pulse treatment) should be the first choice. Azathioprine is usually com- bined with corticosteroids. In severe or unresponsive cases, cyclophosphamide can be given additionally [83]. Anti-TNF- α agents and IFN-α are other new effective alternative agents [19]. Methotrexate is another treatment alternative [67, 68]. 7. https://www.sciencedirect.com/science/article/pii/B9780702040887001103 Nervous system involvement, known as “neuro-BS” (NBS), is seen in about 5–10% of all cases. Clinical and imaging evidence suggests that primary neurologic involvement in BS may be subclassified into two major forms: the first, which is seen in the majority of patients, may be characterized as a vascular-inflammatory central nervous system disease with focal or multifocal parenchymal involvement, mostly presenting with a subacute brainstem syndrome and hemiparesis (intra-axial NBS); the other, which has few symptoms and a better neurologic prognosis, may be caused by isolated cerebral venous sinus thrombosis and intracranial hypertension(extra-axial NBS), occurring in 10–20% of the cases. Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006005-case-presentations.html CVS Informant: patient’s daughter A 58 year old woman presented with the complaints of Chief complaints: Shortness of breath with exertion since 1 year and at rest since 15 days Cough intermittently since 4 months Swelling of both lower limbs on and off since 2 months Swelling of right lower limb since 10 days History of present illness: the patient had complaint of shortness of breath since 1 year which was present with farm work started insidiously, progressing over time, exertional, non seasonal, reached the present state of shortness of breath at rest. Associated with increase during sleeping position and relieved during sitting or standing position. Complaint of cough with expectoration intermittently, associated with worsening of chest pain, not associated with fever, no diurnal variations. Expectorant- whitish to slightly pinkish in colour, not foul smelling, no plugs, no frank blood. Complaint of bilateral pedal edema on and off since 2 months, pitting present, extending till ankles, equal on both sides. Not associated with chest pain, dizziness, loss of consciousness, abnormal sensations of heart beat. Associated with increased frequency of urination since 4 months Past history: No history of similar complaints before 1 year. History of hospitalisation for 3 times in the past one year. Episodes of hospitalisation associated with worsening of shortness of breath, pedal edema and cough. Each time the patient’s attenders gave history of on and off medication intake. No history of diabetes, hypertension, bronchial asthma, tuberculosis, jaundice. No known drug allergies. Family history: no history of similar complaints in the family. No history of sudden cardiac death in the family. General physical examination: The patient appears conscious, cooperative, dyspnoea at rest present. Pulse- rate 86 beats per min Rhythm- regular, volume- low volume, equal pulses on both sides and in all peripheral areas, no radio radial delay, no radio femoral delay. Blood pressure- 120/60mm Hg Jugular venous pressure- engorged vein, pulsation, the patient has hepatojugular reflex Respiratory rate - 24 cycles per minute Spo2 - 96% on room air Pallor- present, no icterus, cyanosis, clubbing, lymphadenopathy. Pedal edema- present, bilateral pitting type, extending till ankles. Cardiovascular examination: Inspection: No deformity or bulge in the precordium, apical impulse seen in sixth intercoastal space 1cm lateral to the midclavicular line, no diffuse pulsations over precordium, no superficial engorged veins. No scars or sinuses over the skin. Pulsations seen on the right parasternal region and in the epigastrium. No prominent pulsations in the aortic, suprasternal area, supraclavicular area, no visible carotid pulsation, no visible pulsations on the back. No kyphosis, scoliosis, drooping of shoulder, winging of scapula. Palpation: Apex beat present in the 6th inter coastal space, left sided, 1cm lateral to the midclavicular line over 2 inter coastal spaces. Parasternal heave present on the right parasternal region, obliterated on pressure. Palpable second heart sound in the pulmonary area, not associated with palpable thrill in the pulmonary area. No other palpable heart sounds, no thrill in carotid pulse, no superficial veins. Percussion- right border of heart- dull ness on percussion seen till 2.5 cms lateral to the sternal border. Other borders not well localised. Auscultation: cardiac rate- about 87 beats per minute Regular in rhythm Mitral area- soft s1 heard, associated with diastolic murmur mid to late low pitched, no presystolic accentutation, more heard on the left lateral position. No radiation of the murmur heard. Difficult to appreciate when the patient initially came to the hospital but better audible after initial management. Pulmonary area- loud p2 heard, no murmur heard, no added sounds Aortic area- s2 with normal split heard, no murmurs or added sounds heard Tricuspid area- no murmurs or added sounds heard Provisional diagnosis- based on the above history and examination the most probable diagnosis is moderate to severe mitral stenosis with frequent acute exacerbations of heart failure. Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006009-case-presentations.html CVS SHORT CASE: 42 year old male patient came to casuality with chief complaints of bilateral pedal edema (pitting type)(l>r) since 15 days, Fever and SOB since 2 days. HISTORY OF PRESENT ILLNESS: The patient was asymptomatic 15 days back until he had bilateral pedal edema(pitting) extending upto shin of tibia. He had an ulcer over left malleoli 10 days back followed by increased swelling of left lower limb. From the past two days he complains of low grade intermittent fever with generalized weakness and shortness of breadth (grade 2-3). HISTORY OF PAST ILLNESS: Not k/c/o DM, hypertension, asthma, epilepsy, Heart disease or tuberculosis PERSONAL HISTORY: He has been consuming alcohol 180ml daily and khaini 2-3 per day for the past 20 years. GENERAL EXAMINATION: The patient is conscious Icterus is present Pedal edema is present Absence of pallor, cyanosis, clubbing, lymphadenopathy VITALS: 1.Temperature:- 98.6 F 2.Pulse rate: 110 beats per min 3.Respiratory rate: 18 cycles per min 4.BP: 100/70 mm Hg SYSTEMIC EXAMINATION: A.CARDIOVASCULAR SYSTEM: • S1, S2 heard • No murmers • Apex beat visible • Diffuse shifted down and out • Palpable p2 • Parasternal heave is present( grade 3) B.RESPIRATORY SYSTEM: • Barrel shaped chest • BAE + • Crepts + right sided lung fields BARREL SHAPED CHEST AP diameter-23 cns, Transverse diameter-23 cms C.EXAMINATION OF ABDOMEN: • Soft, non tender D.CENTRAL NERVOUS SYSTEM: • No Focal Neurological Deficit PROVISIONAL DIAGNOSIS : HFref 2° to CAD b/l PLEURAL EFFUSION AKI ( ? prerenal ) CRS -1 ? ALCOHOLIC LIVER DISEASE R. LOWER LOBE PNEUMONIA ? COPD LEFT LOWER LIMB CELLULITIS. INVESTIGATIONS: Investigations on 1/7/21: Chest X-ray LIVER FUNCTION TESTS:- total bilirubin -2.60 mg/dl Direct bilirubin-1.35 mg/dl AST-75 IU/L ALT-31 IU/L ALP- 157 IU/L total proteins-6.1 g/dl Albumin 3.5 g/dl A/G ratio 1.37. Serum creatinine -2.1 mg/dl Blood urea - 81 mg/dl Serum electrolytes - Sodium - 129 mEq /L Potassium -4.8 mEq /L Chloride - 94 mEq /L HEMOGRAM - hemoglobin -10.3 g/dl Total counts -19400 cells /cumm Neutrophils-92 % Lymphocytes -4% Platelets -1.83 lakhs Smear - RBC- microcytic hypochromic WBC-neutrophilic leukocytosis PLATELETS -adequate CUE- ALBUMIN -2+ sugars - nil Pus cells - 4-6 USG ABDOMEN - bilateral pleural effusion -right > left Mild ascites Left kidney - raised echogenicity 2d Echo - Right atrium, right ventricle, left atrium -Dilated Left ventricle - global akinaesia EF - 30% IVC - dilated ECG- Investigation on 3/7/21: ecg - atrial fibrillation, irregular RR interval Investigations on 5/7/21 : ECG- Hemogram :- Hemoglobin - 10.9 g/dl Total count - 17800 cells/cumm Platelets - 1.13 lakhs Blood urea - 86 mg/dl Serum creatinine - 1.5 mg/dl Serum electrolytes - Sodium - 130 mEq /l Potassium - 3.7 mEq/l Chloride - 88 mEq /l TREATMENT : Treatment on 2/7/21: 1)Fluid restriction <1Lit / day 2)Salt restriction <2gm /day 3)Injection ceftriaxone 1gm IV /BD 4) Tab LASIX 40mg BD ( 8am to 4pm) 5) Tab MET-XL 12.5 mg BD 6) BP PR temp spO2 monitoring 7) Tab AZITHROMYCIN 500mg OD 8) Tab ECOSPIRIN -AV 75/20 mg OD Treatment on 3/7/21 : 1)Fluid restriction <1Lit / day 2)Salt restriction <2gm /day 3)Injection ceftriaxone 1gm IV /BD 4) Tab LASIX 40mg BD ( 8am to 4pm) 5) Tab MET-XL 12.5 mg BD 6) BP PR temp spO2 monitoring 7) Tab AZITHROMYCIN 500mg OD 8) Tab ECOSPIRIN -AV 75/20 mg OD Treatment on 4/7/21: 1)Fluid restriction <1lit/day 2)salt restriction. <2gm/day 3) Inj. ceftriaxone 1gm IV/BD 4)Tab LASIX 40mg BD (8am to 4pm) 5) Tab MET-XL 25mg BD 6) Tab AZITHROMYCIN 500mg OD 7)Tab ECOSPIRIN-AV 75/20 mg OD 8)BP ,PR, temp ,spO2 monitoring 9) tab DIGOXIN 0.25 mg stat Treatment on 5/7/21 : 1)Fluid restriction <1lit/day 2)salt restriction. <2gm/day 3) Inj. ceftriaxone 1gm IV/BD 4)Tab LASIX 40mg BD (8am to 4pm) 5) Tab MET-XL 25mg BD 6) Tab AZITHROMYCIN 500mg OD 7)Tab ECOSPIRIN-AV 75/20 mg OD 8)BP ,PR, temp ,spO2 monitoring 9) tab DIGOXIN 0.25 mg stat Treatment on 6/7/21 : 1)Fluid restriction <1lit/day 2)salt restriction. <2gm/day 3) Inj. ceftriaxone 1gm IV/BD 4)tab LASIX 40mg BD (8am to 4pm) 5) Tab MET-XL 25mg BD 6) Tab AZITHROMYCIN 500mg OD 7)Tab ECOSPIRIN-AV 75/20 mg OD 8)BP PR temp and spO2 monitoring 9) tab DIGOXIN 0.25 mg stat 10) Inj. CLINDAMYCIN 600mg IV/TID . Treatment on 7/7/21 : 1)Fluid restriction <1lit/day 2)salt restriction. <2gm/day 3) Inj. ceftriaxone 1gm IV/BD 4)tab LASIX 40mg BD (8am to 4pm) 5) Tab MET-XL 25mg BD 6) Tab AZITHROMYCIN 500mg OD 7)Tab ECOSPIRIN-AV 75/20 mg OD 8)BP PR temp and spO2 monitoring 9) tab DIGOXIN 0.25 mg stat 10) Inj. CLINDAMYCIN 600mg IV/TID . Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006008-case-presentations.html ENDOCRINE 19 year old male resident of Nalgonda and currently studying intermediate ,came to opd with complaints of : -Itchy Ring leisons over arms ,abdomen ,thigh and groin since 1 and half year . -Purple stretch marks all over abdomen ,lower back ,upper limbs ,thighs since 1 year . -Abdominal distension and facial puffiness since 6 months. - Pedal edema since 3 months. - Low back ache since 3 months . - Feeling low , not feeling to talk to anyone. - Weight gain and decreased libido since 3months. - Loss of libido and erectile dysfunction since 2 months . Pt was apparently alright one and half year ago , when he slowly developed erythematous round leisons which are annular shaped and itchy all over abdomen , upper limb ,groin and inner thigh region . No history of fever back then. No other complaints apart from skin lesions. Pt visited local RMP where he prescribed auyurvedic medications and other creams ( unknown composition as pt don't have them currently ). He also prescribed tablets (unknown composition) . Patient started using all these medications for 1-2 months . Leisons reduced a bit after using medications . Later after 2 months he developed multiple hyper pigmented plaques over lower limbs ,abdomen , for which he again visited same place and used ayurvedic oils over the leisons. He also used clobetasol ointment over the leisons.(for approximately 1 year all over the body) He started noticing pink striae over his abdomen first and later on back and over arms,which were gradually increasing in size . Later he visited a hospital and used miconazole and luliconazole ointments also. He used clobetasol ointment all over the leisons for long time . He started noticing abdominal distension and facial puffiness ,weight gain, but never visited any hospital. Later he developed pedal edema and low back ache since 3 months . His consulted a dermatologist at this point of time who advised to consult physician and prescribed monteleukast , itraconazole tablets ,luliconazole ointment for tenia corporis. He stopped all medications one month ago and visited our opd with complaints of pink striae and easy fatigue ,weakness and low back ache . His brother also gave history of pt being moody and feeling of low self esteem due to multiple leisons. He even complaints pt wouldn't step out of house and always stays indoor and wouldn't interact with others . No complaints of chest pain ,sob , palpitations . No complaints of decreased or frothy urine. No other negative history. No h/o DM,HTN,TB,ASTHMA,CAD. ALLERGIC HISTORY - pt gives h/o allergy to eggs ,brinjal . O/E : Pt was c/c/c BP - 160/100 mmHg Pr - 96 BPM ,regular ,normovolemic . Rr - 18/min Spo2- 98% on ra. Weight - 63 kg. Height - 175 cm. GENERAL EXAMINATION : NO pallor ,icterus ,cyanosis , clubbing, lymphadenopathy. Pedal edema present - pitting type extending upto knee. Abdominal distension present. Moon face present Pink striae noted over anterior abdominal wall and on low back and on upper arms and thighs. Thin skin present . Poor healing noticed over leg ulcers and easy bruising noted . Acne present over face . Acanthosis nigrans noted over neck. GYNECOMASTIA PRESENT . Buffalo hump present . Sparse scalp hair . . Skin examination - Multiple itchy erythematous annular leisons noted all over abdomen , upper limb ,groin and inner thigh region . Multiple hyperpigmented plaques noted over bilateral lower limbs . SYSTEMIC EXAMINATION : CVS - S1S2 heard .No murmurs RS - BAE present . No adventitious sounds . P/A - Soft , distended . No organomegaly . Bowel sounds present . CNS - HMF - INTACT R. L MOTOR SYSTEM - POWER - UL 5/5 5/5 LL 5/5 5/5 Proximal muscles lower limb - power is 4/5 . TONE - NORMAL. REFLEXES - B. T. S. K. A. P R. +2 +2. +1. +2. +1. FELXOR L. +2. +2. +2. +2. +1. FLEXOR. CRANIAL NERVES - NORMAL . Difficulty in getting up from chair was noticed. PROVISIONAL DIAGNOSIS - ? IATROGENIC CUSHINGS SYNDROME . TINEA CORPORIS . DENOVO HTN . INVESTIGATIONS : CBP - HB - 13.4 g/dl TLC - 6,800 PLT - 1.5 lakhs. RBS - 139 mg/dl CUE - ALBUMIN - +1 SUGARS - NIL . PUS CELLS - 3-4 RBC - NIL . LFT - TB -1.03 DB-0.21 ALBUMIN - 3.9 RFT - UREA - 22 SERUM CREATININE -0.6 ELECTROLYTES - NA - 136 K- 4 CL-98 USG ABDOMEN - NORMAL. ECG - SINUS TACHYCARDIA LVH PRESENT. This was picture of striae one year ago when it gradually started : On presentation to opd pictures : 28/05/21 We took dermatologist opinion for tenia corporis where they advised Ointment AMLORFINE FUSIDIC ACID CREAM. SALINE COMPRESS OVER LEISONS. Plan to start anti fungals on next visit once dose of steroids is reduced . OPTHAL opinion Was taken to look for visual acuity and cataract . No features of lens opacities noted . BUT IOP was high ,where they advised to follow up . We advised pt to get fasting 8am serum cortisol levels and was planned to start on low dose steroids to avoid adrenal crisis. 8AM S CORTISOL LEVELS (30/5/21) - 0.46 mcg/dl ( very low) . ( normal range - 4.3-22.4 mcg/dl). In view of lvh pt was started on tab telma 20 mg od . On 3/6/21 - ACTH STIMULATION TEST WAS DONE . BY INJECTING 0.4 ML OF ACTOM PROLONGATUM INJECTION (ACTH) INTRA MUSCULAR @ 7am 1 HR LATER FASTING SERUM CORTISOL SAMPLE WAS SENT . VALUE - 0.73 mcg/dl Indicating there was HPA AXIS suppression and pt was started on TAB HIZONE 15 mg per day in three divided doses @ 8am ,12 pm and 4 pm. Pt was asked to follow up after one month . ON NEXT VISIT : ( 25/6/21). Pt was symptomatically better , pedal edema subsided. Striae were pale in color and we're subsiding. Weight - 67kg Ht -175 cm. Bp- 160/100 mmHg. Pr -88bpm. Dose of Tab hizone was reduced to 10 mg per day in divided doses for one month. In view of low back ache Xray LS spine was done which was normal and pt was advised.: Tab Shelcal 500 OD and Tab Vit D 3 Od. Tab ULTRACET /PO/SOS. Psychiatry opinion was taken and he was diagnosed with moderate depression . In July 2021 pt was complaining of fever ,sore throat and dry cough since 3 days and he was tested positive for COVID 19 , we advised him home isolation and PCM 650 Mg /po /sos . He was advised to continue tab hizone tablets as it was advised. He recovered within one week . Next visit : ( 6/8/21). BP- 170/100 - TELMA DOSE WAS INCREASED TO 40 MG OD. PR - 88bpm.regular , normovolemic. Wt- 69 kg Height - Abdominal girth - 96cm Pt complaints of excoriation over striae and appearance of erythematous macules over abdomen whenever he takes food he is allergic to. Took dermatologist opinion for it . They started him on Tab Itraconazole 100 mg bd. And lulifin cream and tab levocitrixine 5mg od. His brother complaints of depressed mood , pt not going out due to social stigma. Psychiatric counselling was given . He still complaints of low back ache..othropedics opinion was taken and advised to continue Ultracet and tab Shelcal . Cbp , cue and electoltes were repeated which were all in normal range . USG ABDOMEN was done - Normal kidney size bilateral and CMD maintained. No other sonological abnormality noted. As his lesions dint subside we reduced dose of hisone to 7.5 mg per day ,to see response. At this point of time we are now in diagnostic dilemma whether endogenous CUSHINGS is also present in this patient , as he is responding slowly to treatment . We advised him to review after 15 days to see progress . And accordingly plan to evaluate further to rule out endogenous CUSHINGS SYNDROME. FINAL DIAGNOSIS : IATROGENIC CUSHINGS SYNDROME SECONDARY TO TOPICAL CLOBETASOL APPLICATION ALL OVER BODY FOR APPROXIMATELY ONE YEAR. TINEA CORPORIS DENOVO HTN . Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html GIT LONG CASE: A 47 year male patient resident of Nalgonda came with chief complaints of abdominal distension and swelling of bilateral lower limbs since 6 months which is gradually increasing since 10 days and fluid discharge from the umbilical area since 2 days and fever since 2 days. History of present illness Patient was apparently asymptomatic 18 months back then he noticed abdominal distension which is insidious in onset and gradually progessive in nature and subsequently noticed bilateral swelling of lower limbs , he was hospitalized for one week and took medication which increased his urine output and abdominal paracentesis was done and felt better ,, However he discontinued medicine 6 months back and presented with similar complaints where he was hospitalized and treated conservatively , he was hospitalized 3 months back again with similar complaints , again abdominal paracentesis of 1.5 to 2 lit was done. He is on medication , the past 10 days he noticed abdominal distension associated associated with swelling of bilateral lower limbs which started at ankle and progressed upto knee , C/0 of swelling over umbilical region since 3 months insidious in onset , progressive in nature initially of pea nut size now progressed to size of 3* 4 cm where he stratched it and clear yellow fluid started oozing from last 2 days it and it is not associated with blood. H/0 of fever high grade, intermittent in nature not associated with chills, since 2 days, H/0 of anorexia, fatigue and generalized weakness since 3 months,, H/0 of itching present since 3 months, which generalized in onset more on the trunk,, H/0 of disturbed sleep since one month, where he complained of excessive day time sleepiness and night distured sleep, H/0 of yellowish discoloration of eyes 3 months back now it subsided, Past medical illness- History of abdominal distension , swelling of bilateral pedal oedema, and hematemesis one episode 50 ml 18 months back ,where he admitted in an hospital for 10 days which relieved with diuretics , abdominal paracentesis and gastric oesophageal ligation was done. Appendicectomy 25 years ago No history of hypertension, diabetes, thyroid , epilepsy or seizure disorder. Personal history- Diet - mixed Sleep - disturbed , excessive day time sleep , night time disturbed sleep since one month. Appetite- decreased. Bladder habits- regular and normal. Habits- chronic consumption of alcohol since 20 years daily , country liquor of 500 ml nearly 110gm per day, and whisky of 150 ml per day nearly 50gm per day, Last binge of alcohol - 3 days before admission he took 100gm. Summary - Decompensated chronic liver disease secondary to ethanol consumption, with ascites, portal hypertension, hepatic encephalopathy stage 1 and spontaneous bacterial peritonitis. General examination - Moderately built and nourished. Patient is oriented to time , place and person. GCS - E4 V5 M6 VITALS - Pulse - 82 beats per minute, regular normal volume ,and character, no radio radial or radio femoral delay. Blood pressure - 100/70 mm Hg, right arm supine position. Respiratory rate - 18 cpm, thoracoabdominal. Spo2- 98 % on room air Jvp - not elevated. Physical examination- pallor - present Icterus - absent No cyanosis No clubbing No generalized lymphadenopathy Pedal edema + Head to toe examination- Axillary and public hair - sparse. B/ l parotid enlargement - negative No fetor hepaticus No asterixis No gynaecomastia Spider nevi - absent No planar erythema No leuconchyia No evidence of xanthoma and xanthelasma. Flapping tremors - seen. Inspection - Oral cavity - No dental caries and no Tobacco staining Abdomen - flanks full, distension. Umbilical hernia present Appendicectomy scar present. Distened veins present. No visible peristalsis or no visible pulsations. Palpation - Done in supine position with Both Limbs flexed and hands by side of body. No tenderness or local rise of temperature. Abdomen - soft. No gaurding and rigidity Lower border of liver not palpable. Spleen not palpable Kidneys bimanually palpable , ballotable. Fluid thrill - present Abdominal girth - 98 cms . Xiphisternum to umbilicus - 16 cms Public symphysis to umbilicus - 13cms Percussion - Liver span - upper border of liver dullness in 5 th intercoastal space in mid clavicular line, lower border could not be appreciated. Auscultation : Normal bowel sounds heard. No hepatic bruit , venous hum or friction rub. Examination of external genitilia - No testicular atrophy. Examination of spine - Normal. Provisional diagnosis - Decompensated chronic liver disease Etiology - chronic ethanol related. Ascites , SBP, Hepatic encephalopathy ? Hepatorenal syndrome. Esophageal gastric ligation bands were. CTP SCORE - C MELD SCORE - 28. Investigations- CBP - HB - 10.7 TLC - 19100, PLT - 1.50 LAKH N - 90 CUE - Albumin- 2+ Sugar- nil Rbcs- nil Pus cells - 4-5 RFT - Blood urea - 116 mg/ dl Serum creatinine - 4.8 mg/dl Sodium - 128 meq/l Potassium - 5.5meq/l Chloride - 102 meq/l Uric acid - 5.0 Calcium - 9.1 Phosphorus - 8.0 LFT - Total bilirubin - 1.63 mg/ dl Direct bilirubin - 0.40mg/dl SGOT - 34 IU/L SGPT - 20 IU/L ALP - 186 IU/L Total protein - 5.4 gm/dl Albumin - 2.06 gm/ dl RBS- 70mg/dl Ascitic fluid analysis - SAAG - 1.74. Serumalbumin - 2.01 Ascitic albumin - 0.36 Ascitic LDH - 120 IU/ L Ascitic sugar - 52 mg/ dl Ascitic protein - 0.8 g/dl Appearance - Clear Neutrophil count - 405. Total count - 675 RBCS - Present. PT - 16 Sec. APTT - 32sec. INR - 1.11 Hiv - negative. Hbsag -negative. Hcv - negative. ECG - X ray - Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006001-case-presentations.html GIT SHORT CASE - A 60 years old female presented to the casualty with complaints of fever associated with chills and abdominal pain. CHIEF COMPLAINTs ➤Fever for the past 6 days. ➤Pain abdomen for the past 3 days HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 6 days ago after which she developed high grade fever associated with chills, insidious in onset, progressive, not subsiding with medication, continuous type Pain abdomen , sudden in onset, pricking type, in the epigastrium and right hypochondrium which gets aggravated on right lateral position and relieved with sitting posture, associated with nausea and reduced appetite, no association with intake of fatty food No complaints of burning micturition. No complaints of cough, cold or shortness of breath. No complaints of heartburn or flatulence. No complaints of heamatemesis or maleana. No complaints of dysphagia. No complaints of constipation or diarrhoea. No history of yellowish discolouration of eyes or high coloured urine. No history of weight loss No history of any blood transfusion No history of any high risk behaviour HISTORY OF PAST ILLNESS Not a known case of hypertension, diabetes, bronchial asthma, epilepsy. k/c/o tuberculosis and took complete treatment. No history of similar complaints in the past. DRUG HISTORY ➤No significant drug history or intake of toxins. PERSONAL HISTORY ➤Occupation: Daily waged labor working in Cotton fields. ➤Patient is married ➤Patient takes mixed diet but has a decreased appetite. ➤Bowel and bladder movement is normal and regular. ➤occasional Alcoholic , non smoker. - sound sleep FAMILY HISTORY ➤No significant family history. MENSTRUAL HISTORY: G 3 P 4 L 4 A 0 Attained menarche at the age of 20 years, with good flow and volume. Attained menopause at age of 42 years. SUMMARY: 60 year old female with high grade fever and abdominal pain confined to right upper quadrant ,acute in onset, without any alcohol history . Possibly case of 1) Acute Liver injury (?infective etiology) 2)Acute Cholecystitis. GENERAL EXAMINATION Patient is well built, well nourished. ➤Pallor : Not seen ➤Icterus : Not seen ➤Cyanosis : Not seen ➤Clubbing : Not seen ➤Lymphadenopathy : Not seen ➤Edema : Not seen - No signs of chronic liver cell failure - No signs of nutritional deficiency. VITALS ➤Temperature : 101℉ ➤PR : 108 beats per minute ➤BP : 100/70 mmHg ➤RR : 24 cycles per minute ➤SpO2 : 95% in room air ➤Blood Sugar (random) : 100mg/dl SYSTEMIC EXAMINATION ABDOMINAL EXAMINATION INSPECTION ➤Shape - Scaphoid, with no distention. ➤Umbilicus - Inverted ➤Equal symmetrical movements in all the quadrants with respiration. ➤No visible pulsation,peristalsis, dilated veins and localized swellings. PALPATION ➤SUPERICIAL :Local rise of temperature in right hypochondrium with tenderness and localised guarding and rigidity. ➤ DEEP : Mild enlargement of liver, regular smooth surface , rounded edges soft in consistency, tender, moving with respiration non pulsatile ➤No splenomegaly ➤Abdominal girth : 78cms. ➤xiphesternum to umbilicus distance was equal to umbilicus to pubic distance. PERCUSSION ➤Hepatomegaly : liver span of 16 cms with 4 cms extending below the costal margin ➤Fluid thrill and shifting dullness absent ➤puddle sign absent ➤Traubes space : resonant AUSCULTATION ➤ Bowel sounds present. ➤No bruit or venous hum. NO LOCAL LYMPHADENOPATHY PER VAGINAL AND PER RECTAL EXAMINATION : NAD CARDIOVASCULAR SYSTEM EXAMINATION ➤s1 and s2 heard ➤Thrills absent., ➤No cardiac murmurs RESPIRATORY SYSTEM ➤Normal vesicular breath sounds heard. ➤Bilateral air entry present CENTRAL NERVOUS SYSTEM EXAMINATION ➤Conscious and coherent PROVISIONAL DIAGNOSIS : ACUTE HEPATITIS (? INFECTIVE) INVESTIGATIONS : DAY 1 Serum Na+ 126 Serum K+ 4.7 Serum Cl- 92 Serum Creatinine 0.8 Blood urea 40 CUE normal CBP : HB 10.7 TLC 13900 PLATELET 4.02L LFT : TB 2.45 DB 1.59 SGOT 52 SGPT 10 ALK P 191 ALB 2.5 PT/INR 17/1.2 APTT 33SECS ESR 110 BLOOD CULTURES Showed no growth. USG ABDOMEN USG REPORT IMPRESSION- Multiple liver abscess with largest measuring 5*5 cms in the 7th segment of liver , with 40 to 50% of liquefaction , hepatomegaly with liver span of 18.5 cms. CT SCAN XRAY CHEST-POST TB CHANGES FINAL DIAGNOSIS : MULTPLE PYOGENIC LIVER ABSCESS WITH ACUTE LIVER FAILURE. TPR CHART Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006010-case-presentations.html MUSCULOSKELETAL A 44 year old man presented with a 3-day history of bilaterally symmetrical rapidly progressive generalized edema. Present Illness An agile stonemason, the patient reported that this symptom first started suddenly 3 days ago, at night, when he noticed he started feeling facial puffiness with pedal edema. The next morning, while brushing his teeth, the patient noticed he had facial puffiness, in the mirror. At the same time, he also noticed that he developed bilaterally symmetric, pitting type pedal edema, extending upto the middle of his legs. He immediately presented to the hospital with these complaints. On interviewing the patient further, he denied having breathlessness, palpitations or chest pain. He reported frothing of urine but no haematuria. He also reported gradually decreasing urine output over the past 3 days. He did not have pain during micturition, no pus or any other abnormal discharge (casts) in urine. He did not have any history of vomiting or diarrhea, no history of acute retention of urine, no prior history of fever or rash, no history of antibiotic usage or any drugs in the past 1 week. The patient also denied any history of yellowish discoloration of skin or sclera. Prior to this, the patient reported that since 2011, he had severe joint pains, which were initially asymmetric and gradually became bilaterally symmetrical and involving the small joints of his hands and wrist. The joint pains were associated with significant local edema, and painful limitation of movements, which made his job (stonemasonry) difficult. [Other activities which were painful and difficult for the patient were - Holding his cup of tea or glass of water, Pain in his finger joints and wrist while brushing, Pain while holding mug when taking bath and Pain in toes and ankles on both sides when walking)] He reported that he also had debilitating early morning pains and limitation of movements in his hands, wrists and feet, which usually lasts for about an hour, He reported that the pains and limitation of movements improved with activity, with gradual reduction in edema of joints. From 2011 to 2019, these joint symptoms gradually progressed in severity, now also involving several large joints (shoulders, elbows, knees and hips) warranting several medical consults, where he was frequently prescribed pain killers. The patient did not have any documentation of the pain killers he took in these 8 years. In December 2020, he presented to our hospital with similar complaints of joint pains, when he was prescribed with Etoricoxib and Febuxostat (he had hyperuricemia). He reported that his symptoms alleviated with these drugs but he intermittently had worsening of same symptoms in the interim. The patient denied any history of skin rash, photosensitivity, nasal or oral ulcers, chest pain or abdominal pain, weakness in his limbs (such as difficulty in taking stairs or lifting heavy stones and nor any weakness in his distal aspects of limbs such as mixing food, buttoning his shirt or holding a glass or slipping of footwear), isolated single joint pain or edema, or a past history of kidney stones. He also does not have any history of difficulty in swallowing, altered bowel habits, pain in the pulp of his digits, or painful tearing, photophobia or visual loss. He also denied any history of gritty sensation in eyes or dryness of mouth. Apart from these, the patient reported that, for the past 3 days, he has burning sensation in his eyes with increased tearing but no visual deficits. He also reported for the past 1 year, he developed subcutaneous swellings in the proximal joints of his fingers. He denies any history of early satiety or post prandial fullness or pain. He reported that his clothes have slightly loosened over the past 1 year with involuntary weight loss and loss of appetite. He denies having a history of wrist or foot drop, chest pain, palpitations or breathlessness. No history of loss of consciousness, falls or tingling or numbness in his feet or hands. Past History No significant past history. Medical/Surgical History Chronic intermittent use of analgesics (type and dose unknown). Has been using Etoricoxib 60 mg and Febuxostat 80 mg intermittently for the past 8 months. No relevant surgical history. No history of allergy or atopy. Personal History The patient had been working as a stonemason for the past 20 years. He is a devout Catholic Christian and a strict teetotal (has never smoked or consumed alcohol in his life). He stays with his wife and 2 children (elder son and younger daughter) in Miriyalguda. He is from a close-knit family and regularly socialises with his family (parents and his 2 elder brothers). Apart from his troubling joint pains, he used to a have a fairly balanced and good quality of life, with good sleep every night, good appetite and adequate access to nutritious food and clean drinking water. He also had a balanced social well-being with a tightly-knit community at home and his church. However, since the last 1 year, his appetite started to decrease and he also involuntarily lost weight. His bowel and bladder habits have always been normal but these joints pains have forced him into early voluntary retirement from his job in 2019. His and his family's finances have been supported by his brothers and from generous donations from his church. He feels his mental health has remained intact, thanks to his supportive family and fellow churchgoers. Family History No significant family history reported. Social & Educational History Married for 18 years with 2 children. Primary education upto Class 7 in Telugu medium. Immunization History None taken since birth. Problem Representation / History Analysis A 44 year old stonemason from Miriyalguda, presented with a 3 day history of anasarca, frothy urine and gradually decreasing urine output, on a background of a 10 year history of chronic bilaterally symmetric polyarthritis (evidenced by severe pain, edema and limitation of joint movements). Localisation of Acute Problem Anasarca and frothy urine with decreasing urine output suggest a renal pathology. Proteinuria causing anasarca likely due to glomerular pathology. Other systemic causes like heart failure and liver dysfunction can be ruled out due to absence of dyspnea, palpitations, bendopnea or syncope. Liver dysfunction can be ruled out by lack of jaundice, melaena or hematemesis (from bleeding varices), and abdominal distention not occurring prior to pedal edema. Within the kidney, pre-renal and post-renal causes can be effectively ruled out from the absence of volume loss (vomiting, diarrhea, diuretic abuse or burns) and no history of acute retention of urine or lower urinary tract symptoms (LUTS) like frequency, urgency, hesitancy or precipitancy. The presence of frothy urine and edema strongly supports a glomerular pathology due to significant loss of protein and also decreased urine output. Isolated defects in tubular/interstitium are unlikely as such patients have a deficit in maintaining urinary concentration, which causes polyuria. Such a high range of proteinuria causing anasarca is also not seen with tubular/interstitial pathologies alone. Provisional Diagnosis - Acute Glomerulopathy (Glomerulonephritis / Nephrotic syndrome) Features to look for - 1. Hypertension (secondary hypertension in Glomerulonephritis) 2. Haematuria on Urine Microscopy (particularly dysmorphic RBCs in urine) 3. Quantification of Proteinuria 4. Serum Albumin / Total Proteins 5. Urine specific gravity / calculated urine osmolality to check for isosthenuria (to look for secondary tubular/interstitial damage) 6. Renal biopsy, if diagnosis remains uncertain Localisation of Chronic Problem This 44 year old man has a 10 year history of bilaterally symmetrical progressive inflammatory polyarthritis. Features favouring an inflammatory pathology are - 1. Features of inflammation such as severe pain associated with edema of the joints and limitation of range of active movements 2. Early morning stiffness, lasting for more than 30 mins (for 1 hour in this patient) 3. Pain and edema of joints improving with activity and worsening with rest 4. Features of uncontrolled systemic inflammation such as fever, involuntary loss of weight associated with loss of appetite. 5. Swellings at joints and deformation of normal joint posture Provisional Diagnosis - Bilaterally Symmetric Chronic Progressive Inflammatory Peripheral Polyarthritis Clinical Examination Initial examination revealed, the patient was conscious, coherent and co-operative, lying in bed in supine position. He was in some visibly apparent distress with flexion at his elbows and wrists, bilaterally, which were mildly painful when resting on the bed and his abdomen, respectively. The patient was dressed in a round neck t-shirt and when asked to sit up and take his t-shirt off, he had significant pain and limitation of movements at multiple joints but no weakness. Vitals were taken in supine and sitting position - Supine Position Pulse - 92 bpm, regular, normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay. All peripheral pulses were normal. Blood Pressure - 140/90 mmHg Temperature - 99.3F Respiratory Rate - 24 cycles per minute. Mildly acidotic + (with prolonged duration of expiration) Sitting Position Pulse - 96 bpm, regular, normal volume, condition of vessel wall - normal, no radio-radial or radio-femoral delay. Blood Pressure - 150/90 mmHg Head to Toe General Examination General Condition - Fair built and appears well nourished. Hair - Thin and slightly greyed. Not easily pluckable or no areas of scarring or non-scarring hair loss. No lesions noted on the scalp. Eyes - No conjunctival chemosis or injection, No redness or corneal lesions. Bilateral, purplish reticular markings noted on the sclera of both eyes. Palpebral conjunctival pallor +. No icterus. No cyanosis. Bilateral Periorbital puffiness + Periorbital Edema +. Pallor was also + General Head, Neck & ENT - No abnormalities. No lymph node enlargement. Axial - No apparent spinal deformities Fingers and Nails - Leukonychia +. No clubbing or cyanosis. Capillary refill time - 2 seconds. Bilateral pitting type pedal edema +, extending upto middle of legs. Systemic Examination Musculo-Skeletal System Axial Skeleton Inspection - No visibly apparent spinal deformities; Palpation - Inspectory findings confirmed. No spine tenderness. Movements - Atlanto-occipital - Flexion, extension and lateral flexion normal Atlanto-axial - Rotation of head normal Spinal Flexion, Spinal Extension, Lateral Flexion and Rotation are normal Appendicular Skeleton - Upper Limbs (Positive Findings) Shoulders (both sides) - - Inspection - Attitude - Slightly flexed and internally rotated; Contour normal; No edema or erythema - Palpation - Mild increase in temperature on both sides - Range of Movements - Mild Active and Passive limitation of all range of movements (flexion, extension, adduction, abduction, internal rotation and external rotation) Elbows (both sides) - - Inspection - Attitude - mid-flexion; alignment of elbow and forearm - normal; Edema + ; No scars or sinuses; no muscle wasting - Palpation - All Inspectory findings are confirmed; Raised temperature +; Edema +; Wincing on touch + ; Fluctuation test + ; 3 point bony relationship intact - Range of Movements - Severe pain on active movements of flexion, extension; Mild pain with supination and pronation; Wrists (both sides) - - Inspection - Attitude - Mild extension; Radial deviation of wrists +; Diffuse edema +; Redness +; - Palpation - All Inspectory findings confirmed; Temperature raise +; Wincing on touch +; - Range of Movements - Severely limited and extremely painful active movements of flexion, extension, radial deviation and ulnar deviation. Hands (both sides) - - Inspection - Attitude - Palmar subluxation and Ulnar deviation of the MCP joints; Swollen and Erythematous PIP joints; No swelling or redness of DIP joints; No apparent muscle wasting; Mild hyper-extension of PIP of thumbs; Pulp of fingers normal - Palpation - All Inspectory findings are confirmed; Temperature raise +; Wincing on gentle palpation of MCP joints and PIP joints; Palpation of DIP joints is normal; Swellings also + on 3rd and 4th PIP joints on both sides. Z-deformity +. - Range of Movements - Severe pain and severe limitation of active movements of flexion, extension and ulnar and radial deviation of MCP joints; severe pain and limitation of active and passive movements of flexion and extension at PIP joints. DIP joints normal. Appendicular Skeleton - Lower Limbs (Positive Findings only) Hip Joints (both sides) - Limitation of passive movements of flexion and extension (towards the end of range of motion); Knee Joints (both sides) - Inspection - Swelling and erythema + ; Attitude - flexion; - Palpation - All Inspectory findings are confirmed; Raised temperature + ; - Range of movements - Severe pain and limitation of active and passive movements of flexion and extension and lateral and medial rotation; (Patient was unable to stand on Day 1 and was able to stand on Day 2 with analgesic use). Ankles (both sides) - Mild pain and limitation of active and passive movements of plantar flexion and dorsiflexion; Mild pain and limitation of movements of inversion and eversion. - Palpation of Achilles tendon is normal. Foot examination (both sides) - Mild pain and limitation of passive movements of flexion and extension of MTP joints; great toe flexion and extension normal; Other Systems Examination Cardiovascular System - No abnormalities detected Respiratory System - No abnormalities detected Abdominal Exam - No abnormalities detected Nervous System - No deficits detected Investigations X-ray AP view of the hands and wrists - Osteopenia and erosions of the MCP and PIP joints are noted. Scallop sign +. Significant soft tissue swelling is also noted. Chest X-ray PA view - Full inspiratory, underexposed film with no malrotation or angulation. Bones - Clavicle, Head of Humerus, Coracoid process and acromion of scapula appear normal. The ribs are normal. No mediastinal lymph nodes or enlargement. The right heart border shows mildly dilated right atrium. The left heart border shows a prominent aortic knuckle, the pulmonary bay area is normal, the left atrial appendage appears normal and the left ventricular free wall also appears normal. The bronchovascular markings are also prominent, likely due to underexposure. Standard 12 lead ECG with normal voltage and speed @ 25mm/s; P waves, QRS complexes and T waves have normal morphology and duration; P-P and R-R intervals are normal. PR and QTc intervals are normal. Current Admission - Blood tests Blood work from previous presentations to hospital. RA factor was negative 24hrs urinary protein: 1500 mg 24hrs urinary creatinine: 0.8 Urine Microscopy - Freshly voided urine sample was centrifuged at high speed (> 2700 RPM) and sediment collected and fixed on glass slide and examined under microscope at 400 (10x * 40x) showed DYSMORPHIC RBCs (black circles) and occasional pus cells (red circles). Dysmorphic RBCs were those that had altered shape, microcytic or with membrane defects. Diagnostic Approach With a provisional diagnosis of Acute Glomerulopathy on the background of bilaterally symmetric chronic progressive erosive peripheral polyarthritis, features supporting the diagnosis of glomerulonephritis were - - Secondary Hypertension - Oliguria (360 ml urine in the last 24 hours) - Hypoalbuminemia (Serum Albumin 2.5g/dl) and Anasarca - Dysmorphic RBCs in Urine (A review of literature was done to evaluate the sensitivity and specificity of dysmorphic RBCs for glomerular disease pathologies - One study conducted in Bangladesh showed that urinary dysmorphic RBCs were 92.7% sensitive and 100% specific for a biopsy confirmed diagnosis of glomerulonephritis. [1] Similar values of sensitivity and specificity was also confirmed in another study jointly conducted in Australia and China, where glomerulonephritis was confirmed with renal biopsy. [2] ) Thus, with glomerular disease being most likely, an anatomical diagnosis is made. The etiological cause for glomerular injury needs to be ascertained. A careful construction of the problem representation for this patient and insight into the sequence of his life events can provide clues that the current acute problem could be a sequelae of his long term, poorly treated chronic problem. Thus, a good clinical diagnosis of his musculo-skeletal problems is required to get a better picture of his current illness. The patient has Bilaterally Symmetrical Chronic Progressive Erosive Peripheral Polyarthritis. Differential diagnosis for such conditions include - 1. Rheumatoid Arthritis (most likely) 2. Rheumatoid Arthritis with coexistent Gout 3. Psoriatic Arthritis 4. Enteropathic Arthritis 5. Reactive Arthritis 6. SLE 7. Polymyositis / MCTD (Mixed Connective Tissue Disorder) (least likely) With Rheumatoid Arthritis being most likely, ACR/EULAR classification criteria can be applied for diagnosis - This patient has >10 joints involved with multiple small joints involvement - 5 points; Symptom duration 10 years - 1 point; RA Factor - NEGATIVE; CRP elevated & ESR - 120 mm/hr - 1 point; Total Score - 7/10 [3] Treatment 1. Free water restriction for Hyponatremia 2. Tab. PREDNISOLONE P/O 20 mg OD 3. Tab FEBUXOSTAT P/O 80 mg OD 4. Haemodialysis for worsening renal dysfunction Pedagogic Questions 1. Abdominal fat pad biopsy vs Renal biopsy ? The clinical data and biopsy results of 194 SA patients who were treated in Peking Union Medical College Hospital from January 2009 to June 2015 were retrospectively analyzed. Results The highest sensitivity was achieved by biopsy of affected organs,with renal biopsy 97.4%,heart biopsy 95.0% and liver biopsy 87.5%. Among non-invasive biopsy methods,tongue biopsy was found to be 75% sensitive,followed by gingiva biopsy at 57%,abdominal fat pad aspiration at 57%,rectum biopsy at 16%,and bone marrow examination at 8%. Combination of tongue and abdominal fat pad biopsy yielded a detection rate of 93.1%. Conclusions Biopsy of the involved organ has the highest sensitivity. However,combination of multiple non-invasive biopsy methods may has sensitivity comparable to organ biopsy and is safer and more convenient. [7] 2. Single DMARD vs Combination therapy ? A Cochrane review, published in The BMJ [8] looked at the clinical efficacy of Methotrexate monotherapy vs Combination therapy (MTX + Non-biological or MTX + Biologicals). Data of Methotrexate -naïve patients was gleaned from this meta-analysis - Outcomes - The major outcomes of the review were American College of Rheumatology (ACR) 50 response, a composite measure of improvement in disease activity (dichotomous outcome); radiographic progression, measured by Larsen, Sharp, or modified Larsen/Sharp scores (continuous outcome); and withdrawals due to adverse events, including death (dichotomous outcome). 3. When to initiate dialysis ? How long can we wait ? Ex tempore interpretation of the AKIKI-2 trial. [9] 4. Can Rheumatoid Arthritis and Gout co-exist together ? The study population included 813 patients, 537 (66%) were rheumatoid factor positive; 33% had rheumatoid nodules, and 53% had erosive joint disease. During 9771 total person-years of follow-up (mean 12.0 years per RA patient), 22 patients developed gout by clinical criteria. The great toe was the most common site of gout (12 of 22 patients). The 25 year cumulative incidence of gout diagnosed by clinical criteria was 5.3%. Typical intracellular monosodium urate crystals were present in 9 of 22 patients with acute gout; all had developed gout after the RA incidence date. The 25 year cumulative incidence of gout diagnosed by clinical criteria including presence of urate crystals is 1.3%. The prevalence of gout in RA on Jan 1, 2008 was 1.9% (11 of 582 patients) as opposed to expected prevalence of 5.2% (or 30 patients) based on National Health and Nutrition Examination Survey (NHANES) data using age and sex specific prevalence rates. [10] 5. Efficacy of Febuxostat vs Allopurinol for Gout ? [11] References 1. Sultana T, Sultana T, Rahman MQ, Rahman F, Islam MS, Ahmed AN. Value of dysmorphic red cells and G1 cells by phase contrast microscopy in the diagnosis of glomerular diseases. Mymensingh Med J. 2011 Jan;20(1):71-7. PMID: 21240166. 2. Pollock C, Liu PL, Györy AZ, Grigg R, Gallery ED, Caterson R, Ibels L, Mahony J, Waugh D. Dysmorphism of urinary red blood cells--value in diagnosis. Kidney Int. 1989 Dec;36(6):1045-9. doi: 10.1038/ki.1989.299. PMID: 2689749. 3. https://www.eular.org/myUploadData/files/RA%20Class%20Slides%20ACR_Web.pdf. 4. Helin H, Korpela M, Mustonen J, et al. Renal biopsy findings and clinicopathologic correlations in rheumatoid arthritis. Arthritis Rheum 1995;38(2):242–7. 5. Korpela M, Mustonen J, Helin H, et al. Immunological comparison of patients with rheumatoid arthritis with and without nephropathy. Ann Rheum Dis 1990;49(4): 214–8. 6. Horak P, Smrzova A, Krejci K, et al. Renal manifestations of rheumatic diseases. A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2013;157(2):98–104. 7. Zhang CL, Feng J, Cao XX, Zhang CL, Shen KN, Huang XF, Zhang L, Zhou DB, Li J. Selection of Biopsy Site for Patients with Systematic Amyloidosis. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2016 Dec 20;38(6):706-709. doi: 10.3881/j.issn.1000-503X.2016.06.013. PMID: 28065238. 8. Hazlewood GS, Barnabe C, Tomlinson G, Marshall D, Devoe DJ, Bombardier C. Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti‐rheumatic drugs for rheumatoid arthritis: A network meta‐analysis. Cochrane Database of Systematic Reviews. 2016(8). 9. Gaudry S, Hajage D, Martin-Lefevre L, Louis G, Moschietto S, Titeca-Beauport D, La Combe B, Pons B, De Prost N, Besset S, Combes A. The Artificial Kidney Initiation in Kidney Injury 2 (AKIKI2): study protocol for a randomized controlled trial. Trials. 2019 Dec;20(1):1-0. 10. Jebakumar A, Crowson C, Udayakumar D, Matteson E. Co-Existence of Gout in Rheumatoid Arthritis: It Does Happen! A Population Based Study.: 134. Arthritis & Rheumatism. 2012 Oct;64. 11. Huang X, Du H, Gu J, Zhao D, Jiang L, Li X, Zuo X, Liu Y, Li Z, Li X, Zhu P. An allopurinol‐controlled, multicenter, randomized, double‐blind, parallel between‐group, comparative study of febuxostat in C hinese patients with gout and hyperuricemia. International journal of rheumatic diseases. 2014 Jul;17(6):679-86. Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006003-case-presentations.html RENAL A 45 year old female patient farmer by occupation Resident of Nalgonda came to casuality with complaints of vomitings and abdominal pain since 4 days HISTORY OF PRESENTING ILLNESS Patient was apparently asymptomatic 6 days back then she was allegedly bitten by snake on her right lateral foot at 7.30 pm while she was cooking, she was taken to local hospital and started on treatment ( 20 min whole blood clotting test was positive started her on Anti snake venom later shifted here , C/0 of abdominal pain since 5 days, periumbilical in location, non radiating , pain aggravated with food intake relieved with medications . C/0 of vomitings since 5 days 3 to 4 episodes per day, containing non digested food particles non bilious , non projectile in nature, C/0 swelling of right foot non pitting type insidious in onset progressed upto ankle and releived in 2 days C/0 of anorexia , myalgias, fatigue and generalized weakness from 5 days, Past history - No histoy of hypertension , diabetes, thyroid , epilepsy , tuberculosis and asthma. Personal history- Diet - mixed Sleep- adequate Appetite - normal Bowel and bladder - Not a alcoholic or smoker Summary - 45 year old female patient alleged to snake bite , presententing with Nonoliguric Acute kidney injury. General physical examination- Patient was conscious, coherent , well oriented to time place and person Pallor - present No Icterus No clubbing , no cyanosis No lymphadenopathy No edema. Vitals - Temp - 98.6 F ( measured in axilla). PR- 82 beats per min, normal in rhythum, character and volume ,no vessel wall thickening , no radio radial or radio femoral delay. Bp - 140/ 90 mm hg, measured in right upper arm in supine position. RR- 16 cpm. Cvs - S1 , S2 heard, no jvp rise, no murmurs heard , apical impulse- Rs - Non vesicular breath sounds heard, equal bilateral air entry , no added sounds. P/ A - soft , no tenderness elicited, No mass felt, No organomegaly . Bowel sounds heard. CNS - Higher mental functions are normal. Tone - normal power - 5/5 in both limbs, All superficial and deep reflexes are normal Sensory and cerebellar system - intact INVESTIGATIONS- COMPLETE BLOOD PICTURE- HB - 8.5 gm/dl. Platelet count- 63000 WBC count - 9000 RBS- 113mg/dl. Serum creatinine - 7.4 mg/dl. Blood urea - 166mg/dl. BUN - 77.5 Sodium - 124meq/l Potassium - 3.9meq/l Chloride - 75meq/l Spot urine protein creatine ratio - 0.13 . Spot urine sodium - 229 mmol/ L . Complete urine examination- Colour - pale yellow Pus cells - 2-3 Rbcs - nil Albumin - nil Bleeding time - 2min 15 secs Clotting time - 4 min 45 secs. Total bilirubin - 1.0 mg/ dl Albumin - 4.5 gm SGPT - 34 ( 15- 40) SGOT - 24 ALP - 90 IU/L ABG - PH - 7.403 Hco3- 16.7 Pco2-. 22.1 Spo2- 97.2 % Urine protein creatine ratio ,- 0.13 Urinary sodium - 229. X ray - ECG - USG - KIDNEY SIZE - Normal, increased echotexture and mild perinephric fluid likely inflammation. Provisional diagnosis - Acute kidney injury , secondary to acute tubular necrosis , due to snake bite . Treatment - 1. 4 sessions of haemodialysis 2. Inj zofer 4 mg TID 3. Inj pan 40 mg Od 4. Strict input / output charting. High dose vs low dose anti snake venom http://www.ncbi.nlm.nih.gov/pubmed/15633711 Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006001-case-presentations.html RESPIRATORY SYSTEM 26 year old male, construction worker by occupation presented to the casualty with the chief complaints of Fever since 3 months Cough with expectoration since 2 months Dyspnea on exertion since 2 months Vomiting since 2 months Decreased appetite and weight loss over last 2 months Dark coloured stools since 2 weeks. History of presenting illness:- Patient was apparently asymptomatic 3months back till when he attended his relative function where he consumed alcohol for 2days ( Around 8 beers) following which after 2days he developed high grade fever though not associated with chills & rigors or Night sweats and it subsided with medication for 1 week but from then he's having on & off fever. The following month he started experiencing productive cough with mucoid expectoration, blood tinged amounting to 2 to 3 cup's per day it's foul smelling . Cough is more in sitting position & slightly relieved by Lying down on bed & It's more during day time than in night. He also started feeling difficulty in breathing on walking for small distances . It's progressive & currently he has to take a break After walking for 100meters of distance. He's having 2 to 3 episodes of vomiting daily containing food particles. He also complains of loss of appetite and unintentional weight loss of around 10 kgs over the past 3 months from 72kgs to 62kgs. History of black colour stools since 2weeks not associated with mucus or foul smelling. No h/o chest pain, palpitations, syncopal attacks, profuse sweating, Orthopnea or paroxysmal nocturnal dyspnea . Past history:- Not a k/c/o Hypertension, Diabetes mellitus, Asthma, epilepsy, Tuberculosis or any heart diseases. No past history of allergies or surgeries. Personal history:- Diet- mixed Appetite- decreased Sleep-adequate Bowel & bladder- normal Occasional alcoholic, Occasional smoker. Family history:- No h/o similar complaints in family members Drug history:- Patient visited around 4 hospitals in past three month's where he's given multiple antibiotic injections, Antipyretics.. Etc No h/o any drug allergies . Summary at end of history:- A 26yr old male who's a construction worker by occupation and who's an occasional smoker presented with persistent fever, cough with blood tinged expectoration and decreased appetite associated with weight loss since 2months and black color stools since past 2weeks and had a history of reccurent hospital visits & intake of medications for these complaints in past 2months with no history of Hypertension, diabetes or any contact with TB. Differentaial diagnosis:- Lung consolidation Lung abscess General physical examination:- Patient conscious, coherent, cooperative Moderately built & moderately nourished. Height- 165cm Weight- 55kgs BMI- 20.2 Temperature - 100.6f PR - 94bpm, Regular & normal volume, No radioradial or radio femoral delay. All peripheral pulses felt BP - 100/70mmhg Right arm supine position RR - 28cpm, Abdominothoracic type. Spo2 at 98 % on room air. Pallor +nt Icterus -nt Cyanosis -nt Clubbing -nt Lymphadenopathy -nt Edema -nt No Nicotine staining over hand's, lips or any visible wasting of hand muscles Spine appears normal SYSTEMIC EXAMINATION:- RESPIRATORY SYSTEM- Patient examined in sitting position Inspection:- Upper respiratory tract - oral cavity, nose & oropharynx appears normal. Chest appears Bilaterally symmetrical & elliptical in shape Respiratory movements appear equal on both sides and it's Abdominothoracic type. Trachea central in position & Nipples are in 4th Intercoastal space No signs of volume loss No dilated veins, scars, sinuses, visible pulsations. Palpation:- All inspiratory findings confirmed Trachea central in position Apical impulse in left 5th ICS, 1cm medial to mid clavicular line Cricosternal distance is 3finger breadths. MEASUREMENTS- chest circumference- 31 inches at expiration & 32 inches at full inspiration Chest expansion- 2.5cm Right left Hemithorax- 15.5 inches 15.5 inches Hemithorax expansion- 1/2inch 1/2inch AP diameter- 7 inch Transverse diameter- 12 inches AP/T ratio - 0.58 Respiratory movement's:- decreased on Right side. https://drive.google.com/file/d/1t2cmYVK6yu6o3VcOhsvibeqqIxISZ8uS/view?usp=drivesdk https://drive.google.com/file/d/1t41C_0FklIuSHq68BDEh0uEK43_srWWy/view?usp=drivesdk Tactile vocal phremitus- increased in right Infraaxillary & infra scapular area. Aegophony & whispering pectorloquy present in right Infraaxillary & infra scapular area Percussion:- Right left Supraclavicular- Resonant (R) (R) Infraclavicular- (R) (R) Mammary- (R) Dull Axillary- (R) (R) Infra axillary- Dull (R) Suprascapular- (R) (R) Interscapular- (R) (R) Infrascapular- Dull (R) Auscultation:- Right Left Supraclavicular- Normal vesicular (NVBS) Breath sounds (NVBS) Infraclavicular- (NVBS) (NVBS) Mammary- (NVBS) (NVBS) Axillary- (NVBS) (NVBS) Infra axillary- Tubular B.S (NVBS) Suprascapular- (NVBS) (NVBS) Interscapular- (NVBS) (NVBS) Infrascapular- Tubular B. S (NVBS) ABDOMEN :- Inspection : shape of abdomen appear normal & symmetrical No Generalised/Localised distension seen. All quadrants moving equally with respiration Umblicus is central & inverted Skin over the Abdomen- Looks normal No visible Scars/Sinuses/Dilated/Prominent veins / peristalsis/Pulsations . Palpation : All Inspectory findings confirmed Mild Tenderness in right hypochondrium No Guarding/ Rigidity Edge of liver is palpable on deep inspiration Spleen is not palpable Percussion:- Liver span is 15cm from right 4th ICS to right coastal margin along mid clavicular line Spleenic dullness noticed in left coastal margin Auscultation:- Normal bowel sounds heard, no renal bruit heard. CARDIOVASCULAR SYSTEM:- Apical Impulse felt in left 5th ICS, no parasternal heave or precordial bulge felt S1S2 heard No murmers heard. CENTRAL NERVOUS SYSTEM:- Higher mental functions intact No FND, pupils-NSRL. Cranial nerves- Intact Motor & sensory systems- Normal. PROVISIONAL DIAGNOSIS:- Right lung lower lobe consolidation. INVESTIGATIONS:- Hemogram- Hb- 9gm/dl Tlc- 13,700cells/cu mm Plt- 4lakh/cu mm Rft: urea- 10mg/dl Creatinine- 0.9mg/dl Sodium-129mEq/l Potassium-4.1mEq/l Chloride-94mEq/l Lft: Total bilirubin-2.28mg/dl Direct bilirubin-0.52mg/dl SGOT- 109 IU/L SGPT-12IU/L Alkaline phosphate- 313IU/L Total proteins - 7.5gm/dl Albumin-2.7gm/dl Esr- 90mm PT-INR - 20 sec & 1.1 APTT- 39sec BT & CT - 2min & 5min HIV, HBSAG, HCV- Negative ECG:- USG chest:- Consolidatory changes noted in right lower lobe . Chest xray- USG abdomen- A large hypoechoeic lesion measuring 8cm × 8cm in right lobe of liver. CECT abdomen-  Final diagnosis:- Amoebic liver abscess with rupturing into pleural cavity with Right lung basal consolidation. Initially conservative management is planned Treatment:- 1.Inj. Metronidazole 750mg/iv/Tid 2.inj.Ceftriaxone 1gm/iv/bd 3.Inj.pantoprazole 40mg/iv/OD 4.inj paracetamol 1gm/Iv/sos 5.Tab.paromomycin 500mg/Tid 6.syp.Ambrolyte 5ml/Tid 7.Temperature/Respiratory rate /blood pressure/SpO2monitoring. Treatment & vitals charting:- Discussion:- Amoebic liver abscesses most commonly noticed in the age group of 20–45 years and have been noted infrequently in the extremes of ages , with an adult male to female ratio of 10:1 . Our case is of a 26-year-old male patient who presented with the complaint of fever,Cough with Expectoration that's blood tinged, SOB, weight loss for the past three months. The diagnosis of amoebic liver abscess is sometimes difficult since its clinical manifestations are highly variable, like in our patient who presented with a long standing cough with blood tinged expectoration , intermittent high-grade fever, and progressive dyspnoea & weight loss in spite of not having symptoms like right upper quadrant abdominal pain, jaundice, , the patient still had the disease. We report a case of Right lung lower lobe consolidation with central liquefaction secondary to an Ruptured amoebic liver abscess that was misdiagnosed as pneumonia & he was been on multiple antibiotics in outside hospitals . Pleuro-pulmonary amoebiasis is easily confused with other illnesses, and it is treated as pulmonary TB, bacterial lung abscess, and carcinoma of the lung . Aspiration and drainage of pus from thoracic empyema usually will be helpful but in our case it's not presented as empyema Also, it has been recommended that amoebic liver abscess be treated with metronidazole or tinidazole plus a luminal amoebicide (eg. paromomycin or iodoquinol) even if the intestinal infection is not documented . Imaging techniques such as ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) have excellent sensitivity for the detection of a liver abscess and were used with our patient, but these techniques cannot distinguish amoebic abscesses from pyogenic abscesses or necrotic tumor. The diagnosis of an amoebic liver abscess is confirmed with either serologic or antigenic testing. It can also be coupled with stool microscopy and antigen testing of the stool, with or without evaluation for the parasite in the hepatic abscess fluid. Due the combination of findings in the imaging studies like hepatomegaly, pleural effusion with thick loculated collection, obliteration of costophrenic angles, left subdiaphragmatic collection, and involvement of the right lung which suggested an basal consolidation of the right lung, the patient was treated with a percutaneous liver abscess drainage. Following drainage, the fever improved dramatically as he continued to be under observation. Blog Link: https://2018-21batchpgy3gmpracticals.blogspot.com/2021/08/18100006004-case-presentations.html