Final practical examination- short cases

 

CBBLE UDHC SIMILAR CASES 

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

Case 1:

A 52 year old woman, home maker from Nalgonda, came with the chief complaints of swelling over left retroauricular and mandible region ,associated with pain since 1 week.

History of presenting illness 

Patient was apparently asymptomatic 2 months back ,when she developed itchy skin lesions all over the body, initially small in size, gradually progressed to present size. Patient diagnosed with tinea corporis et cruris and treated with antifungals - itraconazole and luluconazole cream .

History of ulcer over lateral aspect of left leg 1 month back,associatedwithpain and swelling, used antibiotics and currently ulcer has healed.

History of swelling over left auricular and mandible region since 1 week

Associated with redness and pain during movement.no History of fever, trauma, went to a local hospital, found to have high sugars nd referred to our hospital for further management. Swelling diagnosed as acute parotitis and started on antibiotics.swelling has reduced over the past few days and pain subsided.

Past history 

Patient was apparently asymptomatic 8 years back, had h/o fever for which she went to a local hospital and on routine investigations found to have high blood sugars and started on oral hypoglycemics (tab glimeperide 1mg +metfomin 1000mg) once daily. on regular follow up and was added metformin 500 mg at night 4 years back.

7 years back- had hernioplasty in view of incisions hernia( previous 4 LSCS in v/o ?delayed labour).

2 years back - pt had c/o giddiness for 1 month 1-2 times a day,  lasting for few seconds, no postural variation, nausea or vomiting.,associated with headache. Diagnosed with hypertension and started on tab. Telmisartan 40 mg od.

Personal history 

She is a home maker, wakes up at 7 am, does house chores( washing and cleaning dishes),prepares breakfast (idly,dosa), has breakfast with family members, takes break, prepares lunch, has h/o increased appetite since past 10 yrs, consumes around 2 cups of rice with vegetables,  has non veg twice a week, takes nap for few hours ,has tea/coffee in the evening and has dinner (rice).

History of increased urine output since 5-6 years, has to get up 2-3 times at night, no h/o burning micturition.

Non smoker and occasional toddy drinker 500ml once in 2-3 months.

Menstrual history 

Attained menarche at 13 years  of  age

Normal cycles, regular, 3/ 30, no clots

Attained menopause  years back.

Vitals 

Temperature  - afebrile 

Pulse rate - 86 beats per minute, regular

Respiratory rate - 16 cycles per minute

Bp - 140/90 mmhg

Spo2 -97%

Grbs- 259 mg%

General examination 

Patient is conscious, coherent 

Oriented to time ,place and person

Moderately built and nourished

Acanthosis nigricans +

Abdomen - obese 

Multiple lesions with plaques with scaling present over neck , trunk ,upper and lower limbs.

No Pallor, icterus, cyanosis, clubbing , pedal edema. 

Height - 160 cms

Weight- 88 kgs

BMI - 34.3

Waist circumference - 113 cm

Waist to hip ratio -0.89

Arm circumference - 31 cm

Serum triglycerides  - 650 mg /dl

HbA1c - 15

Cardiovascular system examination 

 

S1 and s2 heard

No murmurs 

Apex beat felt at left 5 th intercoastal space lateral to mid clavicular line 

Jvp normal

Respiratory system examination 

Shape of chest - elliptical 

All areas moving equally with respiration

 No scars or sinuses ,

Normal vesicular breath sounds heard over all the areas

Abdomen examination 

Shape of abdomen- distended ,obese

All quadrants moving accordingly with respiration 

C - section scar present

No visible sinuses or engorged veins 

Linear striae over Abdomen present

No local rise of temperature,  tenderness on palpation 

No palpable masses or organomegaly

Percussion - resonant note 

Bowel sounds heard. 

Cns examination 

No focal neurological deficits

No sensory loss in all dermatomes 

Fundus - no diabetic or Hypertensive retinopathy changes

Usg abdomen - grade 1 fatty liver

Diagnosis 

Metabolic syndrome ( type 2 diabetes,  hypertension, hypertriglycerdemia, obese )

With tenia corporis et cruris

And b/l parotitis (resolving)

Case 2 :

A 48 year old woman , daily laborer from nakrekal came with the chief complaints of abdominal distension since 6 months 

Shortness of breath since 18 months 

Pedal edema since 18 months

History of presenting illness 

Patient was apparently asymptomatic 3 yrs back, had c/o giddiness for 1 week 2-3 episodes per day,  each episode lasting for 1-2 minutes and relieved spontaneously on rest. She went to a local hospital, diagnosed as having hypertension and started on antihypertensive ( tablet not known) , used them for 3 months and stopped as  bp became

normal and as the complaints subsided, she was not on follow up. 

History of decreased appetite,  nausea , vomitings -non projectile , non bilious, food as content 18 months back

History of pedal edema since 18 months , which is bilateral , pitting type, painless, initially upto ankles, gradually progressed upto knees, no aggravating or relieving factors associated with decreased urine output and facial puffiness. Shortness of breath since 18 months, initially grade 2 gradually progressedto grade 3, aggravated on work , relieved on taking rest.

She went to a local hospital where she was told to have kidney failure and referred to higher center for dialysis. 

She visited our hospital where she was diagnosed with Heart failure with preserved ejection fraction and renal failure and started on dialysis.

Since 6months, pt complaining of abdominal distension, gradually progressed to present size, with increased shortness of breath on lying down, dyspepsia and decreased appetite .no aggravating factors, symptomatic relief after dialysis. Ascitic fluid paracentesis done with high SAAG transudative picture.

Past history 

Hypertensive since 3 years

History of 1 LSCS 25 years back

Non smoker ,toddy drinker 2-3 times per week

Vitals

Temperature  afebrile 

Pulse rate  76 beats per minute

Respiratory rate 20 cycles per minute

Blood Pressure 150/80 mmhg

Spo2 -96 %

General examination

 Patient is conscious, coherent and coperative

 Pallor + 

No icterus , cyanosis ,clubbing, generalized lymphadenopathy. 

Pitting type of pedal edema present upto knees bilateral 

A v Fistula over right forearm present

ABDOMEN EXAMINATION:

Inspection 

Abdomen distended , tense, flanks full 

Umbilicus central in position ,everted 

Longitudinal striae present over lower Abdomen

Longitudinal c section scar present below the umbilicus extending upto public tubercle .

No visible sinuses 

Engorged veins present

Palpation

No local rise of temperature 

No tenderness 

No mass 

Liver and spleen not palpable

Percussion

Shifting Dullness  absent

Fluid Thrill  present

Auscultation 

Bowel sounds heard

Cardiovascular system examination

Shape of chest elliptical

No scars or sinuses 

No precordial pulsations 

Jvp elevated

Apex beat felt at 6 th intercoastal space lateral to mid clavicular line 

S1 s2 heard 

No murmurs 

Respiratory system examination 

Respiratory movements equal on both sides

Decreased breath sounds at right infra axillary area

Normal vesicular breath sounds heard

CNS examination 

No focal neurological deficits 

Investigations 

Hb - 8.6

Tlc _ 5500

Plt -1.7 lakhs

Serum Urea  90 mg/dl

Creatinine 5.6 mg/dl

Total bilirubin- 1.0

Direct - 0.4

AST -40

ALT --38

ALP- 120

Total protein- 5.5

Albumin 3.0

Diagnosis 

Ascites secondary to heart failure with preserved ejection fraction 

Cardiorenal syndrome type 3 on maintenance hemodialysis 

Hypertension since 3 years