General medicine case-3

8th September 2021

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A 21 year old female presented to the OPD with chief complaints of fever(intermittent), generalised weakness, body pains since 4 months. Cough since one month.

History of present illness

The patient was apparently asymptomatic 4 months back before standing illness. The patient was presented to the casualty approximately 15 days back with fever which is intermittent, generalised weakness of the body, body pains since 4 months, cough since 1 month and vomiting a day back. The patient was unable to even stand 1 day back and so was rushed to the hospital.

Patient had a history of hypothyroidism 1 year back for which she was taking medications like thyronorm 50 mcg,

Few months back patient had a history of anaemia for which patient  medications were taken.

Since 4 months patient had been facing body pains and generalized weakness which were thought to be normal by the patient. But the body pains had been increased gradually.

1 month back patient had vomitings without blood tinge for which symptomatic treatment had been taken.

1 day before admitting the hospital,patient had 2 episodes of vomitings and on the day of admission patient had difficulty in getting up from the bed and could move the limbs with alot of difficulty for which the patient was admitted to the hospital.

Past history 

No history of DM/HTN/Epilepsy/TB/Thyroid disorders

The patient had not undergone any surgeries.

Personal history 

Diet : mixed

Appetite : decreased

Bowel and bladder : normal 

Sleep :adequate 

Addictions:none 

Family history

No history of DM/HTN/CVA/CAD/Asthma/thyroid disorders

No similar complaints in the family previously. 

Treatment history

Not significant. 

Systemic examination:

Patient is conscious,coherent and cooperative.

Her vitals are stable.

CARDIOVASCULAR SYSTEM:

Inspection:

S1,S2  heard

Auscultation:

Normal with regular heartbeat

S1, S2 heard

No murmurs 

RESPIRATORY SYSTEM-

Lungs: reduced breath sounds bilaterally.

PER ABDOMEN:

Negative

CENTRAL NERVOUS SYSTEM

Lower limb reflexes absent.

Abdominal reflexes absent.

Sensory system:

Patient couldn't appreciate fine and crude touch below the level of umbilicus.

Later on 27/08/21

Patient had ptosis of left eye.

Neck stiffness is also seen 

Patient was unable to move the body.

Investigations:

On 27/08/21

Hemogram: 

RBC: 4.09 million/cumm

WBC: 12300 cells/cumm

Hb- 8.4

PLT- 4.8 lakh/cumm

Aptt- 32 sec

PT - 16 sec

INR. - 1.11

BT - 2 min 

CT - 4 min 

ESR - 90 mm in 1st hr

CUE: 

Albumin- nil

Sugars- nil

Pus cells - 2 to 3

Epithelial cells - 2 to 3

Blood urea- 22 mg/dl

Serum creatinine - 0.6 mg/dl 

TB- 0.70 mg/dl 

DB. - 0.19 mg/dl 

Na+ - 132 meq/lit

K+ - 3.4 meq/lit

Cl- : 94 meq/lit

ALP: 236 IU/lit

SGOT: 13 IU/LIT

SGPT: 10 IU/LIT

Serum protein: 6.5 gm/dl 

Serum magnesium: 2.2 mg/dl

Serum calcium: 9.6 mg/dl

Serum albumin: 2.4 gm/dl

Peripheral smear- Microcytic hypochromic anemia with leucocytosis 

On 03/08/21

Hemogram:

RBC-4.24 mil/cumm

WBC-18600 cells/cumm

PLATELETS- 5 lakhs/cumm

Hb-9

CUE:

Albumin-nil

Sugars-nil

Pus cells:2-4

Epithelial cells:2-3

Blood urea:22mg/dl

Serum creatinine:0.6mg/dl

Na+:132 meq/l

K+:3.4meq/dl

Cl-:94meq/dl

ALP:236 IU/L

SGOT:13 IU/L

SGPT:10IU/L

Serum proteins:6.5 gm/dl

Total bilirubin:0.70 mg/dl

Peripheral smear- Microcytic hypochromic anemia with leucocytosis 

MRI BRAIN IMPRESSION 

Acute infarct involving the genu of the corpus callosum on the left side

MRI cervico-dorsal spine:

Cervical spine and cord are normal.

Long segment intramedullary hyperintensity involving the central portion of dorsal cord form D2 level upto conus medullaris.

Provisional diagnosis:

? PULMONARY KOCH'S 

B/L PARAPLEGIA

HYPOPROLIFERATIVE ANEMIA SECONDARY TO NUTRITIONAL ANEMIA 

 Investigations:

On 26/08/21

On 28/08/21

On 29/08/21

Treatment:

On 26-08-2021:-

1) IV FLUIDS NS

2) Inj.Optineuron 1 ampoule in 100 ml NS IV/OD

3) Inj.Pan 40 mg IV/OD

On 27-08-2021:-

1) IV FLUIDS NS,RL

2) Inj.Optineuron 1ampoule in 100ml NS IV OD

3) Inj.Zofer 4mg IV/TID

4)Tab THYRONORM 50 mcg

5)Tab Clopidogril 75mg

On 28-08-2021:-

1) IV FLUIDS NS,RL

2) Inj.Optineuron 1ampoule in 100ml NS IV OD

3) Inj.Zofer 4mg IV/TID

4)Tab THYRONORM 50 mcg

5)Tab Clopidogril 75mg

On 29-08-2021:-

1) IV FLUIDS NS,RL

2) Inj.Optineuron 1ampoule in 100ml NS IV OD

3) Inj.Zofer 4mg IV/TID

4)Tab THYRONORM 50 mcg

5) Tab benadon 40mg

On 03-09-2021:-

1) IV FLUIDS NS,RL

2) Inj.Optineuron 1ampoule in 100ml NS IV OD

3) Inj.Zofer 4mg IV/TID

4)Tab THYRONORM 50 mcg

5) Tab benadon 40mg

6)Pregabalin 75mg PO BD

7)Inj.Mannitol 100ml/IU/TID