Med case

A 44 yr old female came with C/O abdominal distension since 5 months 

Pedal edema since 15 days

Patient is a telugu teacher by occupation and her routine includes - Wakeup at 6 AM and then cooking, washing dishes, having breakfast at 8 AM 

At 8:30 AM, she will go to school, teaching till 1PM then lunch and again teaching till 4 PM.

Again at evening , back to home and then cooking, washing dishes, clothes, dinner at 8PM and to sleep at 10:00 PM

Birth History :                                                         Term, Normal vaginal delivery, Normal weight at birth. Attained all milestones acc. to age

At 16 yrs of age, she noticed ? group of vesicles over Right cheek (? Herpes Zoster) for which she used medication and got relieved.

She got married at the age of 20yrs 

Obstetric history :

Conceived spontaneously after 5 years of marriage

First Pregnancy - abortion, spontaneously @ 3months

Then she was diagnosed with hypothyroidism on medication 50mcg

6 months later, Second Pregnancy - abortion spontaneously @ 3 months

6 months later, Third pregnancy - abortion spontaneously @ 3 months

1 year later, 4th pregnancy - delivered at 8th month, preterm baby with wt. of 1.5 kg ( At the age of 1 year, baby died due to dengue )

Past History:

In 2017, patient had c/o pain in MCP, PIP joints sparing thumb and DIP joints. Knee joint pain +

No involvement of Ankle, Elbow and shoulder joints

Pain relieved on medication ( wysolone 5 mg/ tadalafil 20mg/ HCQ 200mg ) . Then she was diagnosed with mixed connective tissue disorder

At the same time, she had c/o SOB, diagnosed with PAH, continued same medication (on &off due to affordable issues )

Inbetween 2018 - 2020, she used to have intermittent complaints of SOB, where it reduced by taking tadalafill 20mg stat

In 2020, due to covid pandemic she stopped visiting hospital and continued to take all medications (irregularly)

In Dec 2020, she went to another centre with c/o SOB and since then she is on medication irregularly until Jan 2022.

In Jan 2022, patient had c/o abdominal distension, decreased appetite, abdominal tightness even after consumption of little amount of food.                                Constipation +. No H/o fever, cold, cough, jaundice, pedal edema.

She then went to local hospital and not relieved on medication. 

In march 2022, Advised for ascitic tap which was done 4 times (once for every 15 days) over the last 2 months

On 5th April 2022, ascitic fluid sent for investigation  & Started ATT, used for 20 days (ADA -34.7) - No other ascitic fluid investigation reports are not available

After starting of ATT, C/o Giddiness, Generalised weakness, orange yellow coloured urine, SOB (grade II - III), Constipation +

On 2nd May 2022, ATT was stopped 

Now on 12th May 2022, she came with c/o abdominal distension since 3 months, pedal edema (pitting type) since 15 days 

C/o Blisters over right lower limb which were ruptured  and healed on its own 

No c/o Nausea, vomitings

No c/o Fever, cold, cough

No c/o loose stools

No c/o chest pain, palpitations, syncopal attacks

Stopped wysolone / HCQ / tadalafil 10 days back

No c/o Altered sleep patterns, Asterixis, Essential tremors, spider neavi

On examination :

BP - 130/70mmHg

PR - 79 bpm

RR - 16cpm

CVS - S1S2+

RS - BAE +

P/A - Distented , No organomegaly               Abdominal striae +

B/L pitting edema +

Dermatology Referral done i/v/o blisters over right limb

Investigations :

       

 

        

Blood urea - 11 mg/dl

Serum creatinine - 0.8 mg/dl 

Na+ -  136 mEq/L

K+ -  4.1 mEq/L 

Cl-  99 mEq/L 

Ascitic fluid analysis :                                           protein - 2.6 g/dl                                                     Sugar - 90 mg/dl                                                  Amylase - 27 IU/L                                                     LDH - 110 IU/L                                                        Ascitic albumin - 1.38 gm/dl                                    SAAG - 0.98

HIV - Non Reactive                                                HBsAg - Negative                                                      Anti HCV Antibodies - Non Reactive

Outside CT :  

ECG

2D ECHO

 

        

         

Chest X ray

Ultrasound : 

Provisional diagnosis - 

Ascites under evaluation secondary to ? TB

H/o hypothyroidism 

H/o severe PAH

Treatment - 

1) Fluid Restriction < 1.5lt/ day

2) Salt Restriction < 2gm/ day

3) TAB LASIX 20mg PO/ BD

4) TAB ALDACTONE 50mg PO/ BD

5) SYP LACTULOSE 15ml PO/TID

6)ABD. Girth & Wt charting 12th hrly

SOAP NOTES

Day 2 

14/05/22

S: 

c/o burning sensation over right foot at blister region

SOB on exertion grade 2-3

No fever spikes

O:

Pt is c/c/c 

Temp - 98°F

Bp - 110/80mmHg

PR - 81bpm

CVS - S1S2 +

RS - BAE+, B/L ISA crepts +

P/A - Distended, No Organomegaly

A: 

Ascites under evaluation

secondary to ? TB

H/o hypothyroidism

H/o severe PAH

P: 

plan for therapeutic ascitic tap around 1 lt

1)FLUID RESTRICTION <1.5L/day

2)SALT RESTRICTION <2gm/day

3)TAB LASIX 20mg PO/BD

4)TAB ALDACTONE 50mg PO/OD

5)TAB TADALAFIL 20mg PO/OD

6)TAB THYRONORM 75mcg PO/OD

7)SYP LACTULOSE 15ml PO/TID

8)FUDIC CREAM L/A BD

9)MUCOPAIN GEL L/A BD (20mins before food)

10)Abd. Girth & Wt Charting

SOAP NOTES

Day 3

15/05/22

S: 

c/o abdominal distension

No fever spikes

O:

Pt is c/c/c 

Temp - 98°F

Bp - 110/80mmHg

PR - 81bpm

CVS - S1S2 +, P2 reduced

RS - BAE+,

P/A - Soft, Distended, No Organomegaly

A: 

Ascites under evaluation

secondary to ? TB

H/o hypothyroidism

H/o Severe PAH

P: 

1)FLUID RESTRICTION <1.5L/day

2)SALT RESTRICTION <2gm/day

3)TAB LASIX 20mg PO/BD

4)TAB ALDACTONE 50mg PO/OD

5)TAB TADALAFIL 20mg PO/OD

6)TAB THYRONORM 75mcg PO/OD

7)SYP LACTULOSE 15ml PO/HS

8)FUDIC CREAM L/A BD

9)MUCOPAIN GEL L/A BD (20mins before food)

10)TAB PAN 40mg PO/OD

11)TAB ATARAX 25mg PO/OD

12)TAB TAXIM 200mg PO/BD

SOAP NOTES

Day 4

16/05/22

S: 

c/o abdominal distension

No fever spikes

O:

Pt is c/c/c 

Temp - 98°F

Bp - 100/80mmHg

PR - 78bpm

CVS - S1S2 +, P2 reduced

RS - BAE+,

P/A - Soft, Distended, No Organomegaly

CELL COUNT OF ASCITIC FLUID :

Appearance - clear

Colour - pale yellow

Total count - 45 cells/cumm

Neutrophils - 40%

Lymphocytes - 60%

RBC - Nil

Others - occasional mesothelial cells seen

Volume - 2ml

A: 

Ascites under evaluation

secondary to ? TB

H/o hypothyroidism

H/o Severe PAH

P: 

1)FLUID RESTRICTION <1.5L/day

2)SALT RESTRICTION <2gm/day

3)TAB LASIX 20mg PO/BD

4)TAB ALDACTONE 50mg PO/OD

5)TAB TADALAFIL 20mg PO/OD

6)TAB THYRONORM 75mcg PO/OD

7)SYP LACTULOSE 15ml PO/HS

8)FUDIC CREAM L/A BD

9)MUCOPAIN GEL L/A BD (20mins before food)

10)TAB PAN 40mg PO/OD

11)TAB ATARAX 25mg PO/OD

12)TAB TAXIM 200mg PO/BD

13)TAB MVT PO/OD

ESR - 30

C- reactive protein - Positive  (1.2mg/dl)

Ascitic ADA - 33 U/L

SOAP NOTES                                                                 Day 6                                                                      18/05/22

S: 

c/o abdominal distension

No fever spikes

O:

Pt is c/c/c 

Temp - 98°F

Bp - 110/80mmHg

PR - 78bpm

CVS - S1S2 +

RS - BAE+,

P/A - Soft, Distended, No Organomegaly

A: 

Ascites under evaluation

secondary to ? TB

H/o hypothyroidism

H/o Severe PAH

P: 

PLAN TO START ATT

1)FLUID RESTRICTION <1.5L/day

2)SALT RESTRICTION <2gm/day

3)TAB LASIX 20mg PO/BD

4)TAB ALDACTONE 50mg PO/OD

5)TAB TADALAFIL 20mg PO/OD

6)TAB THYRONORM 75mcg PO/OD

7)SYP LACTULOSE 15ml PO/HS

8)FUDIC CREAM L/A BD

9)MUCOPAIN GEL L/A BD (20mins before food)

10)TAB PAN 40mg PO/OD

11)TAB ATARAX 25MG PO/OD

12)TAB MVT PO/OD

Med case 1

 A 56yr old male came with C/O fever since 2 months

Patient was apparently asymptomatic 2 months back and then have fever, high grade, associated with mild chills and rigor.  ( 100°F —> 104°F) associated with cervical lymphadenopathy. 

Not associated with Cold, Cough, Headache, Bodypains.

K/C/O DM  since 30 years (on medication Glicazide 80mg + Metformin Hydrochloride 500 mg)

Not a K/C/O HTN, Asthma, Thyroid disorders, Epilepsy.

Family History of DM ( Father, Grand Father and Great Grandmother ) + . Now his son (aged 29 years) also diagnosed with DM 4 months back

Patient is a publisher by occupation though he completed BAMS. He is very passionate about his work and never neglected his work for any reasons. He  used to do alot of physical work before but Now he hired other persons to do the work to reduce work stress and do monitor their work. 

Since Childhood (around 3 years of age), he is using spectacles for nearsightedness (myopia). From then to till date his power remained same.

At the age of 4 years(In 1970), Patient’s father noticed a small swelling (asymptomatic) on the right side of the neck for the first time and then they went to local hospital where they said it was a lymph nodal swelling for which treatment was taken and size was reduced.

He married at the age of 14 years. (Third degree consanguinity)

At the age of 27 years, patient had a history of fall from bus because of giddiness for which he was taken to hospital and high blood sugars were noted.Then he was diagnosed with DM for which medication was prescribed and he used it for around 1week. Later, he started homeopathy medication for 2 n1/2 years and then stopped as his sugars levels were in control. After the fall incident, where he sustained head injury and from the very next day he had memory loss for 6 months. ( patient just remembered he had a fall because of giddiness and then went home, talked to his wife about paying fare to his transport - auto driver who helped him then. On the following morning after he woke up he din’t remember his wife/kids ). Till now he had no memory of those 6 months. 

At the age of 50 years, he again started Anti diabetic medication (his present medication) as his sugars were quite high. Started with taking 1/2 tablet BD and then increased to 1 tablet BD and present taking 1n1/2 tab in the morning and 1 tablet in the night. 

Again in 2018, patient noticed swelling on the right side of the neck which was progressive for 3-4 months to the present size. It was painless. He was on medication ( probably  ? ATT) for 2 months                  ( prescribed by family doctor). They used medication for 1 month and later they din’t have the access to get the medication as it was unavailable (then patient came to know he was using some high medication) . Then for the second month he was advised to register with red cross and done the same where he then got the medicine based on his old prescription. 4 months later, Montoux test was done which came negative. He continued the same medication for 1 year. After that, again montoux test was done at government hospital  which was negative again where then they advised to stop the medication as he was on wrong (unnecessary) prescription.

Then FNAC was done which suggests - Granulomatous Lymphadenitis (possibly of koch’s etiology) 

And then patient came to know he has No TB. 

In 2021, patient’s father was deceased ( patient was very close with his father, felt depressed and sad then) ,he had to attend some religious rituals for 13 days where he was non compliant with anti diabetic medication. 

Later in March 2022, he went to hospital for the complaints of fever, high grade and they said it was associated with his swelling for which CT scan of chest and Bronchoscopy was done. He then took TAB CEFTUM for 7 days which he felt was not effective for him. Since March, he used to take DOLO 650mg everyday 8th hourly. He took little food as it was not felt good on tasting and sometimes it was nauseous on intake of rice. His appetite is normal along with fluid intake. He lost around 14 kgs of weight. 

In April 2022, he came to our hospital with complaints of fever everyday which was high grade and then admitted for biopsy which was not done as patient had to attend some personal works. There he got fever and local doctor prescribed MEFTAL and patient got no fever for 3 days. Then he again got fever on following 4th day and took MEFTAL again along with TAB AUGMENTIN BD on 25th april for which he got no fever till date. He was admitted here again on 28th april

 Chest X ray

ECG 

USG NECK

2d ECHO

Hemogram :

CUE : 

LFT :

Blood urea - 16 mg/dl

Serum creatinine - 0.7 mg/dl

Na+ - 140 mEq/L

K+ - 5.0 mEq/L

Cl- 100 mEq/L

RBS - 223 mg/ dl, FBS -100mg/dl, PLBS - 178mg/dl

Absolute Eosinophil Count - 200 cells/cumm

Provisional diagnosis - 

Pyrexia of Unknown Origin with Right Cervical Lymphadenopathy

 ? Kochs

 ?Sarcoidosis

 ? Lymphoma

Treatment :

TAB DOLO 650mg PO/TID 

TAB AUGMENTIN 625mg PO/BD 

TAB PRIZIDE - M80 1n1/2 tab—X—-1tab

(Glicazide 80mg +Metformin 500mg)

TRUECUT BIOPSY

Medicine case 2

 

A 42 yr old female came with complaints of headache since 5-6 years. Retro orbital pain +

Patient was apparently asymptomatic 6 yrs back and then developed headache and retro orbital pain. Pain was present continuously through out the day and aggravates in the evening and subsides after taking medication (pain killers).

She was asymptomatic 6 years back.

8 years back her mother died of cancer

7 years back her father died of drowning in water

6 years back her differently abled brother died of cancer.

She is worried about getting the cancer herself as people tell her that she might get cancer as both her mother and younger brother had died of cancer.

She is traumatized with the thought she might also die since six years due to cancer. 

She has two sons aged 25 and 23. Elder son is working in construction industry as labourer in kerala. Younger son is in village completed his BA degree. She says they are having financial challenges and she is worried about her sons too. She is worried that some health issue may affect them too. 

Psychological Course of treatment:

Placebo pain medication

Cognitive behaviour therapy

Not a k/c/o DM, HTN, TB, Asthma

No H/o major surgeries in the past

Tubectomised 23 yrs back

Appetite - Normal

Diet - Mixed

Sleep - Adequate

Bowel and bladder movements - Regular 

Habit of Ghutka chewing

O/E :

Pt is c/c/c

Temp - Afebrile

BP - 110/80 mmHg

PR - 79 bpm

CVS - S1S2 +, no murmurs

RS - BAE +, clear

P/A - Soft, NT

CNS - NAD

ENT opinion - 

Headache - insidious, progressive, band type, aggravated in the night, relieved partially on medication associated with photophobia, phonophobia. Nausea +

No H/o trauma to head. No H/o facial heaviness, post nasal drip & smell abnormalities.

No H/o Nasal obstruction, Nasal discharge, paroxysmal sneezing, itching in the nose.

O/E: Grade I tonsillar Hypertrophy +.                              

Mild tenderness present on B/L ethmoid &frontal sinuses.                                                                       - No symptoms suggestive of chronic Rhinosinusitis

Ophthal opinion - 

                 Right Eye           Left Eye 

   V/A:        6/12 . NI              6/6

 Normal fundus study

Advised regular spectacle use for near vision

Eye drops LUBREX 4times/day in both eyes

Provisional diagnosis :

 ? Somatoform disorder with depression

Treatment - 

TAB DOLO 650 mg SOS

TAB NAPROXEN 250 mg SOS

TAB PAN 40mg PO OD

TAB MVT PO OD