WARD CASE PRESENTATION

Dr. Maaz SeeratPGR-1West Medical Ward

PATIENT BIO DATAName :- Ayesha Akhtar

Sex :- FemaleOccupation:- student Age:- 20yrs. Resident:- 259 Model colony, Sialkot.DOA: 28-10-13MOA: OPD

PRESENTING COMPLAINTS

Progressive generalized Weakness- for last 6

months

Fever 10 days

Bodyaches 6 days

Vomiting 2 days

HISTORY OF PRESENT ILLNESS

6 months back patient started feeling weakness,

malaise, which was on doing daily household work.

It has progressed since then (disability grade 3)

There is associated shortness of breath, which progresed

from NYHA class I to NYHA class II over past 6 months. It

was not associated with cough , whistling sounds on

breathing or blood from loss from any site of the body

HISTORY OF PRESENT ILLNESS Fever started 6 days back, was low-grade,

not associated with rigors and chills, it was intermittent. Relieved only by taking anti pyretic. It was also associated with body aches, restlessness, decrease appetite. It was not associated with joint pain or swelling. There was no body rash associated with this fever

HISTORY OF PRESENT ILLNESS

Vomiting for 2 days There have been 3,4 episodes, containing

food contents. It was non-projectile.it was relieved by anti-emetic drugs.

Vomiting was associated with intake of food and water

SYSTEMIC REVIEW

No history of diarrhea, constipation No history of mental confusion, fits or any

disorientation or headache. No history of cough, sputum No history of burning micturition, pain flank,

yellowing of urine or stools. No history of rash, allergy, difficult in swallowing

food and discolouration of fingers with cold weather exposure

PAST HISTORY

No evident past medical or surgical history

SOCIOECONOMIC

Low middle class

DRUG HISTORY

Patient taking steroids, left 2 months back

EXAMINATION General Pysical Examination:- A young girl, lying comfortably. Well oriented

in place, person and time, having vitals of: BP 110/60 mm Hg pulse 92/min,regular no radioradial and radio

femoral delay R/R 19/min temp:98.4F GCS 15/15 Pallor ++ Cyanosis –ve Jaundice ++ no lymph node

palpable JVP not raised No Pedal Edema

SPECIFIC EXAMINATION

GIT:- Umbilicus central inverted, flat Soft, Non-

tender abdomen.

On palpation Spleen is palpable 1-finger breadth

below left sub costal margin. No other viscera

palpable.

On percussion SD and FT are absent

Bowel sounds +ve.

CVS:-

No visible pulsations, Apex beat in left 5th

intercostal space, medial to mid-clavicular

line.

No thrill, S1+S2+0. no murmur.

Heart rate is 93/min, regular.

CNS:- Higher mental functions are normal Pupils are B/L equal and reactive to light and

accommodation Cranial nerve examination is normal Normal motor and sensory examination of

both the upper and the lower limbs Reflexes are normal

RESPIRATORY SYSTEM

Normal on Inspection, palpation and

percussion.

Normal vesicular breathing with no added

sound

DIFFERENTIAL DIAGNOSISAll types of hemolytic anemiasPortal hypertensionLeuemiasLymphomasMononucleosusMalaria

INVESTIGATIONS

INVESTIGATIONS

INVESTIGATIONS

LFT’S

LFTS

USG ABDOMEN

ANA/ RA

FURTHER INVESTIGATIONS Coomb’s test, direct and indirect to detect

IgG antibodies Hemoglobin electrophoresis

TREATMENT Replace red cells by Pack cell volume

transfusion. Cortisteroids Plasmaphoresis in severe cases. Spleenectomy