20100006010 CASE PRESENTATION

 LONG CASE 

48 year old male patient from devarakonda,Farmer in cotton field and also works as daily wage labourer ,came with the cheif complaints of 

Burning sensation of both lower limbs since

8months

Slippage of slippers since 8months

Hypo pigmented skin lesions on both lower limbs since 8months



HOPI:

Patient was apparently asymptomatic 8months ago when he developed difficulty in holding slippers ,gradually progressive and worsened over last 2months so much so that he stopped wearing slippers,No difficulty in getting up from squatting position,mixing food ,buttoning the shirt,combing hair,no difficult in lifting the head off the pillows,rolling over the bed,no difficulty in breathing or diurnal variation of the weakness

Complaints of burning sensation of both lower limbs gradually progressive since 8 months and has worsened over the last 2months associated with numbness,decreased sleep because of burning sensation,Not associated with tingling or paraesthesias.Patient is able to feel clothes and warm water and cold water during bath.

Complaints of severe pins and needle sensations over outer aspect of leg and patient noticed that when he taps his leg just below the knee on the outer aspect he feels a shock like sensation and pain radiating down on the outer aspect of both legs.No h/o any excess crossed leg sitting posture

No h/o any sensation of walking on cotton wool,no complaints of neck pain ,back pain,band like sensation,

Unsteadiness on closing the eyes+

No h/o Washbasin attacks

No h/o any loss of consciousnesses or altered sensorium,seizures,head injury or trauma to the leg,speech disturbances,no bowel or bladder incontinence,memory disturbances

Sleep disturbances+

No h/o any delusions,hallucinations,emotional disturbances

No h/o any altered no difficulty in sensing smell,vision ,hearing

No tinnitus ,vertigo taste

No difficulty in lifting shoulder,deviation of mouth

Able to roll the tongue and push the food backwards

No h/o any spillage of food while taking it to the mouth or clumsiness of hands

Unsteadiness while walking and closing eyes+

No h/o any palpitations,sweating,able to feel bladders fullness,initiate micturition,feel the passage of urine,able to completely evacuate the bladder

No h/o any bowel disturbances

No h/o Fever ,vomitings,neck pain,trauma,lifting heavy objects on head /back,headache,vomiting,diarrhoea,

Incidentally found to be hepatitis B positive 20days back

Complaints of hypo pigmented skin lesions over both lower limbs since 6months and reduced sensations over the skin lesions.

Complaints of weight loss of 7kgs over the last 4-5 months.

Complaints of transient pain in right upper abdomen and was treated conservatively for gall bladder stones 10days ago.


Past history:

Not a k/c/o DM,HTN,CKD,epilepsy,asthma,TB

No h/o similar complaints in the past


Personal history:

48 Yr old male studied upto 10th class and stopped further studies because of financial issues and started working as a farmer.

Married at the age of 15

Has 1Son 2daughter,all of them married

Alcoholic since 25years and stopped one year back

Non smoker

Mixed diet

Regular bowel and bladder habits

Disturbed sleep patter since 2months


Family history:

No significant family history.


Treatment history :

tenofovir alfenamide since 20days

Pregabalin


Summary:Chronic,Progressive,Distal muscle weakness and sensory involvement probably due to lesion at the level of peripheral nerves at multiple levels ,likely secondary to a infective etiology (Hansens)



General examination:

Patient is conscious,coherent ,cooperative

Thin built

Afebrile to touch

pallor absent

No icterus ,cyanosis,clubbing,lymphadenopathy,pedal edema,no evidence of any neurocutaneous markers






Vitals:

PR:86bpm ,Regular ,normal volume,character,No RR delay,RF delay

BP: 110/80mmhg measured in upper limb in sitting position

Postural drop :absent

RR: 16/min regular ,abdominothoracic

Temp: afebrile


CNS:


Higher mental functions:intact

Cranial nerve examination:

Olfactory-Normal

Optic-

  Visual acuity.  Cf6 both eyes

  Pupils:B/L Normal size,Direct and indirect reflexes +

  Accomodation reflex+

Occulomotor,trochlear,abducens

    No ptosis,EOM normal

Trigeminal:

   Chewing normal

   Facial sensations normal

Facial:

   Frowning normal

   No deviation of mouth

Vestibulochoclear:

   Rinnes-AC>BC both ears

   Webers-no lateralisation 

Glossopharyngeal 

   Uvula central

 Vagoaccesory

   Shrugging of shoulders normal

Hypoglossal

   Normal tongue movements


MOTOR

Attitude :Sitting on the couch with hands placed on the sides and bilateral foot dangling downwards 


Bulk:                           R.                 L

UL-Arm.                 22cms.        22cms

     -Forearm.         21cms.         21cms

LL. -Arm.               33.5cms.    33cms

       -Forearm.        24.5cms.    24.5cms

   

Tone.

     Ankle:                    Hypotonia        Hypotonia  

Upper limbs and knee normal.         Normal

Power:

 1.neck flexion.         Normal        

 2.Neck extension   Normal          


                                   R.                  L

Upper limb.  All:      5/5.               5/5

 3.Supraspinatus.  

4.Deltoid

5.infraspinatous

6.Rhomboids

7.Serratus anterior

8.Pectoralis major

9.Lattismus dorsi

10.Biceps

11.Brachioradialis

12.Triceps

13.Hand muscles 


Trunk muscles :Normal.        


Lower limbs:

1.Iliopsoas.                    5/5.              5/5

2.adductor femoris      5/5.              5/5

3.Gluteus medius.         5/5.             5/5

4.Gluteus maximus       5/5.             5/5

5.Hamstrings.                 5/5.            5/5

6.Quadriceps femoris.   5/5.           5/5

7.Tibialis anterior.           0/5.           0/5

8.Tibialis posterior.         5/5.           5/5

9.peronei                          0/5.           0/5

10.FDL.                             5/5.           5/5

11.EDL.                             0/5.            0/5            

12.EHL.                             0/5.            0/5. 

13.EDB.                             0/5.            0/5


Reflexes:

Superficial reflexes:

Corneal+

Conjunctival+

Abdominal

Plantar.                            Mute.          Mute


DTRs:

Biceps.                             2+.               2+

Triceps.                            2+.               2+

Supinator.                        2+.               1+

Knee.                                2+.               2+

Ankle.                             Absent.       Absent


EXAMINATION VIDEO:

Examination video


Gait:High stepping/equine gait



No primitive reflexes

No involuntary movements


SENSORY:


Crude touch

   Upper limbs -normal bilaterally 

   Trunk-normal

   Lower limbs-reduced in the lower 1/3rd of anterolateral leg

    Reduced over the Dorsum of foot,web space between 1,2nd toes,lateral aspect of foot bilaterally



Pain:

     Upper limbs -normal bilaterally 

     Trunk-normal

     Lower limbs-reduced in the lower 2/3 rd of anterolateral leg

      Reduced over the Dorsum of foot,web space between 1,2nd toes,lateral aspect of foot bilaterally


Vibration:Reduced distally 


Timed Vibration test:      R.              L

Lower limbs:

      Great toe.                  Absent.    Absent

      Medial mallelus.       Absent.    Absent

      Knee.                          Absent.    4.5Sec

Upper limbs:

      Ulna.                           6.7sec.    7.0sec

      Medial epicondyle.    7sec.       7.2sec


Joint position.                  Absent.   Absent


Fine touch :normal in all limbs ,trunk except for reduced fine touch in lower 3rd of anterolateral leg,dorsum of foot

Absent fine touch in the web of 1st and 2nd toe in right lower limb and reduced in left lower limb


Rombergs -Positive (swaying with eyes closed)


Stereognosis: normal

Graphaesthesia:Normal

Tactile localisation:couldn’t be elicited properly 


CEREBELLAR SIGNS:

No titubation

Finger nose test,Finger finger test-normal

Heel knee test -normal

No rebound phenomenon

No dysdiadokokinesia


ANS:

Postural hypotension-absent

Resting tachycardia -No

Abnormal sweating -No


MENINGES:

No signs of meningeal irritation


SPINE AND CRANIUM:

normal

No spinal tenderness


PERIPHERAL NERVES:

-Thickened nerves:

Lower limbs :




Bilateral common peroneal palpable

Bilateral sural nerve palpable

Tibial nerve-not palpable on both sides


Upper limbs:

Ulnar nerve -Palpable in left cubital tunnel


-No ulcers

-bilateral foot drop +

-No wrist drop


CAROTIDS pulse-Normal ,no bruit


LOCAL EXAMINATION-






Multiple marked hypopigmented and hypoanesthetic patches seen over bilateral foot

Asymmetrical 

Surface:Dry

surrounding erythema :absent

central healing:No

elevated margin:present

Clarity of margin:good


CVS:Apex 5th ICS,0.5 inch medial to mid clavicular line,Heart sound normal ,no murmur


RS:Tracheal central,Chest elliptical bilaterally symmetrical

Chest movements normal

Normal vesicular breath sounds


P/A :Soft,Non tender

No organomegaly .


Final diagnosis:Chronic peripheral neuropathy with Mononeuritis multiplex pattern involving bilateral superficial peroneal,deep peroneal,Sural nerves in both sensory and motor component with both small and Large fibre involvement 


DD1:Most probably secondary to Hansens(Late stage as large fibres are also involved)

In favour of :?Borderline Tuberculoid leprosy,

Few skin lesions with

Early nerve involvement

Assymetrical nerve thickening

Hypesthesia and myopathy


DD2:L5 radiculopathy

Justification for Not radiculopathy:

1.No radicular pain

2.No spinal tenderness

3.No clear cut dermatomal distribution of sensory loss


DD3:Hepatitis B induced peripheral neuropathy? Polyarteritis nodosa with mononeuritis multiplex


DD4:Vasculitis -PAN,Wegeners

1.Age not in favour

2.Hypopigmented hypoanesthetic patches can’t be justified

3.No h/o any constitutional symptoms,Organ dysfunction 

4.small fibre involvement predominates


DD5:

Diabetes

Not in favour because:

1.In diabetes Small fibre predominates

2.No history of diabetes


DD6:

Lymes disease:No evidence of any erythema chronicum,Fever,Arthritis


DD7:

Entrapment:Sarcoidosis,Amyloidosis

No other evidence suggestive of these



Further evaluation needed:

1.Slit skin smear from the most hypoanaesthetic macule and skin biopsy

2.Nerve biopsy

3.Nerve conduction study

4.Serology -HIV ,Hepatits B,C

5.HBV viral load,Fibroscan,LFT

6.FBS,PLBS for any impaired glucose tolerance and diabetes



INVESTIGATIONS:

Hb:9.9gm/dl

TLC:7,800

Platelets :2.91

PBS:NC/NC


RBS 80

Urea:32

Creatinine:0.7

Na:141

K:4.1

Cl:102


Total bilirubin 0.37

Direct bilirubin 0.19

AST 16

ALT. 19

ALP. 162

Total protein 5.3

Albumin 3.1

A/G:1.45


CUE:WNL


HBsAG +

HCV-

HIV -


USG abdomen:Norma size and echotexture of liver,cholelithiasis +


ECG:



Nerve conduction study done 8 months ago:Showing reduced CMAP s in bilateral common Peroneal nerve and reduced SNAP in left sural nerve




Plan for split skin smear and biopsy




-----------------------------------------------------------------------------------------------------------------

SHORT CASE I

CHIEF COMPLAINTS

Abdominal distension since 3 months

Shortness of breath since 3months

Pedal edema since 3 days


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 4 months ago, then he developed yellowish discolouration of eyes ,intermittent and reappeared again since 4days not associated with itching,discolouration of urine or stool

Abdominal distension  which was insidious in onset , gradually progressive in nature since 3months,not associated with pain abdomen.

He complained of shortness of breath since 3months (grade 2) upon doing ordinary activity like walking to his field after eating.He used to walk 2km without any inconvenience but since 3 days he is able to walk upto 1km only. He also complained of pedal edema since 3days which was insidious in onset, gradually progressive and confined upto ankles( grade 1) and pitting type.

H/O decrease in urine output since 3 days and difficulty in passing stools and passing hard stools since 3 days which relieved on taking medication.

H/ O yellowish discolouration of eyes  on and off since 4months

No H/O blood in urine, burning micturition, increased frequency and urgency.

No H/O orthopnea, paroxysmal nocturnal dyspnoea

No H/O abdominal pain, nausea ,vomiting, dark stools and diarrhoea.

No H/O chest pain, palpitations, facial puffiness

No H/O fever, chills, rigor, myalgia, joint pain and  rashes.

No H/o any blood transfusions

No H/o any bleeding manifestations 

3 months back diagnosed as decompensated liver disease for which he was treated here and he continued taking medication since discharge and stopped taking them since two days before developing the recent symptoms.

Endoscopy was done here 3 months back and oesophageal varices were detected.


PAST HISTORY:

No H/O hypertension, diabetes mellitus, tuberculosis, asthma, coronary artery disease, epilepsy.

No H/O any surgeries.


FAMILY HISTORY

No similar complaints in the family.

PERSONAL HISTORY 

Patient is a 50 year old male hailing from thanamcherla, who is farmer by occupation, married(  consanguineous) at 20 years and has three children.(2daughters and 1 son)

Stays along with his wife and son.

Daily routine : He wakes up at 5'O clock and goes to his 1acre farm by walk, comes back after an hour, eats breakfast and lunch which are rice and vegetable.He takes afternoon nap for one hour, then again goes to his farm for sometime and comes back for dinner and then sleeps.

Sometimes he also goes for work at municipal office and from there to cleaning roads,schools.


Diet : vegetarian, stopped eating non vegetarian foods 3 months back.

Appetite : normal

Sleep : adequate

Bowel movements: decreased

Bladder movements: decreased 

Addictions :  Alcoholic since 30 years but Started drinking more alcohol along with his friends at municipal office,he had been drinking 1litre of sara (Local alcohol) from the last 10-15years, but stopped from past 3 months on doctor's advice.Slowly drinking with his municipal office friends has become his daily routine.


GENERAL EXAMINATION:

Patient is conscious,coherent and co operative, well oriented to time, place and person 

Patient is moderately nourished and moderately built 

Height -5’5

Weight -60kgs

Pallor -present

Icterus -present

Cyanosis- absent

Clubbing - absent

Lymphadenopathy - absent

Pedal edema - present (grade 1,pitting type)

Parotidomegaly+




EXTERNAL MARKERS OF LIVER CELL FAILURE

HEAD AND NECK- No alopecia, no bitots spots, no xanthelasma, subconjunctival hemorrhage, pallor +, icterus+, no medial supraciliary madarosis, sunken eyes and cheeks, loss of facial hair, no parotid enlargement, bleeding gums

TRUNK - no spider nevi, no gynaecomastia, loss of pectoral/axillary hair present, no dilated veins, wasting, abdominal distension present, no caput medusae, no loss of pubic hair, no testicular atrophy, no scratch marks, purpura

UPPER LIMBS - dupuytrens contracture present, no bounding pulse, no clubbing, no flapping tremor, no palmar erythema, no pruritic marks

LOWER LIMBS - Pedal Edema present










NO BONY TENDERNESS, GUM HYPERTROPHY, LEUKEMIA CUTIS


VITALS 

Afebrile 

Blood pressure-110/70mm Hg

Pulse-78bpm,Regular rhythm,normal volume and character and no RR ,RF delay,all peripheral pulses normal

RR-18cpm, abdominothoracic



SYSTEMIC EXAMINATION 


ABDOMINAL EXAMINATION:

INSPECTION-

Abdomen is distended

Umbilicus is inverted

Skin is normal without any scars

No discolouration of skin ,engorged veins,sinuses 

No visible peristalsis or pulsations 

Hernial orifices Normal 

Movements of abdominal wall equal in all quadrants with respiration 

External genitalia normal


PALPATION-

Superficial palpation:Abdomen is non tender and no local rise in temperature 

No guarding and rigidity 

Deep palpation:Palpation by dipping method -No organomegaly 

PERCUSSION-

liver :Upper border of liver dullness is percussed at the right 6th ics along mid clavicular line and lower border cannot be palpated

Spleen:cannot be palpated

No fluid thrill  

shifting dullness present

AUSCULTATION-

Bowel sounds heard 12/min

No bruit or venous hum

PER RECTAL:stool stained


CNS EXAMINATION:

No flapping tremors

Conscious,coherent and cooperative 

Speech- normal

No signs of meningeal irritation. 

Cranial nerves- intact

Sensory system- normal 


Motor system:

Tone- normal

Power- bilaterally 5/5 in all limbs

Reflexes: Right. Left. 

Biceps. ++. ++


Triceps. ++. ++


Supinator ++. ++


Knee. ++. ++


Ankle ++. ++


CARDIOVASCULAR SYSTEM EXAMINATION:

Inspection : 

Shape of chest- elliptical ,bilaterally symmetrical

No engorged veins, scars, visible pulsations

JVP - not raised

Palpation :

Apex beat can be palpable in 5th inter costal space half inch medial to MCL

No thrills and parasternal heaves can be felt

Auscultation : 

S1,S2 are heard

no murmurs.


RESPIRATORY SYSTEM EXAMINATION:

Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 


Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 


Auscultation:

bilateral air entry present. Normal vesicular breath sounds heard.


PROVISIONAL DIAGNOSIS 

Decompensated chronic liver disease (Cirrhosis)2° to chronic alcohol consumption with ascites with history of esophageal varices without any upper GI bleed with no evidence of hepatic encephalopathy,Spontaneous bacterial peritonitis or other complications 


INVESTIGATIONS


USG ABDOMEN:

Irregular coarse echotexture of liver 

Mild splenomegaly 

Gross ascites s/o chronic liver disease 

 


ECG



CHEST X RAY




ECHO



No RWMA,Good LV systolic function,No PAH



HEMOGRAM :

Hb-9.5g/dl

TLC-8,800cells/cumm

Platelets-1.71lakhs/cumm

PBS-normocytic normochromic anemia


LFT

Total bilirubin-1.65mg/dl

Direct bilirubin-0.25mg/dl

AST-20IU/L

ALT-11IU/L

ALP-205IU/L

Total protein 5.9gm/dl

Albumin -2.0

A/G-0.54


RFT-

Urea-14

Serum creatinine-0.9

Na+ 136

K+ 3.4

Cl- 102


PT-19sec(PTc-10-16sec)

INR-1.4

APTT-39sec(APTTc-24-33sec)


Rapid HCV Negative

Rapid HBV Negative



Ascitic fluid analysis

Cell count -100cells/cumm,100% lymphocytes

Glucose-165

Protein-1.0

Serum albumin-2.0

Ascitic Albumin-1.0

SAAG-2

Gram stain-No growth

Culture and AFB negative


Endoscopy:Grade 4 esophageal varices


Final diagnosis-Chronic Decompensated liver disease secondary to alcohol with features of portal hypertension such as ascites,esophageal varices,Splenomegaly with no evidence of hepatic encephalopathy,SBP


Treatment:

1.Fluid restriction 

2.Salt restriction 

3.Therapeutic paracentesis done-1litre

4.Tab LASIX 40mg BD

5.Tab aldactone 50mg BD

6.Syrup Lactulose 20ml PO TID


Child Pugh score -9, Grade B with one year survival at 80% and 2 year survival at 60%.

Counselled about liver transplantation 

 

----------------------------------------------------------------------------------------------------------------

 

SHORT CASE II 

 

45 year old female currently working as ECG technician and previously worked also a tailor ,hailing from Nalgonda with the chief complaints of multiple joint pains and swellings since 17years


HOPI:

Patient was apparently asymptomatic 17years ago and then developed multiple joint pains,Started with left ankle severe pain and swelling,Gradually progressive ,involving multiple joints ,bilaterally symmetrical,involving ankle joints,knee,hips,shoulder ,elbows to currently involving wrist ,ankle pain still present .History of neck pain 5-6years ago subsided now,3days back history of pain during chewing on lateral cheek with swelling on both sides, relieved after 1day.Pains Relived transiently with pain killers.

Pain Relieving on activity Morning stiffness lasting 20-30ki minutes.No h/o any Deformities.

No h/o any fever,Oral ulcers,facial rash,photosensitivity,breathing difficulty,tingling numbness of limbs or weakness of limbs,bleeding manifestations 


PAST HISTORY:

Hypothyroidism diagnosed 10YEARS ago (visited hospital in view of weight gain)

Epigastric pain—>Gastric ulcer detected 2years ago

Diabetes incidentally detected 1year ago

Diagnosed to be having Seronegative Rheumatoid arthritis 15years ago (Anti CCP,ANA negative,CRP+)

H/o ?Insecticide poisoning 20years ago managed conservatively.

No H/o Asthma,COPD,TB,DM,HTN,CAD,Epilepsy


PERSONAL HISTORY:

Mixed diet

Appetite good

Bowel and bladder habits regular

Sleep adequate

No addictions

H/o weight gain 60->75kgs over 15years

Sleep adequate

No Food allergy


FAMILY HISTORY:

No significant family history


MENSTRUAL HISTORY:

Age of menarche-13years,5/28,no clots,normal flow


OBSTETRIC HISTORY:

P2L2A0

2children ,by LSCS

Last child birth:20years ago

1st child -Male

2nd -female


TREATMENT HISTORY:

Tab WYSOLONE 5mg OD used for 3years,5years ago

Tab Methotrexate 15mg once weekly used 5 years ago

Tab HCQ started 4 years Ago and used for 3 years

Tab Sulphasalazine 1000mg started 4years 

Tab Metformin 500mg PO OD

Tab Pantoprazole 40mg OD


Provisional diagnosis:Bilaterally symmetrical chronic progressive inflammatory peripheral polyarthritis 


EXAMINATION:


Patient is conscious,coherent and cooperative

Well built,well nourished

Height :155cms

Weight:74kgs

BMI:

VITALS:

Pulse:96bpm ,regular,normal volume and character,condition of vessel wall,no RR or RF delay

BP:140/80mmhg in right arm in supine position

Temp:Afebrile

RR:24cpm


GENERAL PHYSICAL EXAMINATION:

Pallor present

Icterus absent

Cyanosis absent

Clubbing absent

Lymphadenopathy absent

Edema-Bilateral pitting type of pedal edema upto lower 3rd of legs


Other head to toe findings:

No scarring or non scarring alopecia 

Eyes normal

Skin ,Nails normal

Oral cavity normal


Pictures showing ankle swelling






LOCOMOTOR SYSTEM EXAMINATION:

1.PIP :Normal

2.DIP:Normal

3.MCP:Normal

4.Carpo metacarpal:Mild Tenderness + over 1st 2 carpometacarpal joints on both sides

5.Wrist :normal on inspection ,palpation and normal range of movements

6.Elbow:placed in mid flexion,normal alignment of arm and forearm,no muscle wasting,no tenderness,3point bony relation intact,ROM normal

7.Shoulder:

Slightly flexed internally rotated,normal contour,no edema or erythema,no increase in local temperature,Range of movements normal,Overhead abduction slightly painful

8.Acromioclavicular: Normal


9.Sternoclavicular:Normal


10.Temporo Mandibular joint:

Tenderness+,chewing movements normal,mild swelling +


11.Hip joint

Normal on inspection,palpation and normal range of flexion and extension

12.Knee joint 

Inspection:swelling present ,in flexion attitude

ROM:

13.Ankle joint

Tenderness on plantar and dorsi flexion+

Painful restriction of motion(flexion ,extension,inversion and eversion)

Achilles tendon palpation normal

14.Subtalar joint

Tenderness +,Swelling+

15.small joints of foot

MTP:Normal

Great toe:Normal


Examination of Spine:

Cervical spine:

Atlanto axial joint -normal neck flexion and extension

Atlanto occipital joint -normal neck rotation

Thoracolumbar spine : normal on inspection ,palpation

Sacroiliac joint:No tenderness,Schobers test negative


Examination of Respiratory system,Cardiovascular system,CNS,Per abdomen -Normal


PROVISIONAL DIAGNOSIS:

Bilaterally symmetrical chronic progressive peripheral polyarthritis

DD:

1.Rheumatoid arthritis

2.Sero negative arthritis-?Reactive,?Psoriatic 

3.Connective tissue diseases,SLE


ACR/EULAR criteria:

Number of joints involved-Multiple small and large joints:5points

Symptoms >6weeks:1 point

RA factor negative:0 points

CRP ESR elevated :1point


Total 7/10


INVESTIGATIONS:


CBP

Hb-9.8

TLC-8600

N/L/E/M/B-68/25/2/5/0

Platlets -4.5

MICROCYTIC HYPOCHROMIC ANAEMIA 


FBS-106

PLBS-241

HbA1c-7.0


THYROID PROFILE

T3-1.06

T4-12.03

TSH-4.15


LIPID PROFILE

Total cholesterol-190

Triglycerides-238

HDL-39

LDL-118

VLDL-47.6


RFT

Urea-24

Creatinine -0.7

Uric acid-2.2

Calcium-9.3

Phosphorus -3.1

Sodium-135

Potassium-4.6

Chloride-101


LFT

Total bilirubin-0.60

Direct bilirubin -0-15

SGOT-22

SGPT-17

ALP-173

Total proteins-5.8

Albumin -3.5

A/G ratio-1.58


RA factor:Negative

Anti CCP :Positive














X ray hands:osteopenia and erosions of MCP and PIP joints,Ankle

Decreased joint space in bilateral knee joint


Final diagnosis:Bilateral symmetrical erosive polyarthritis -Rheumatoid arthritis since 15years with hypothyroidism since 7 years and diabetes mellitus since 1 year




 

 

Comments

Popular posts from this blog

GM PG FINAL YEAR (2K20-23 BATCH) UNIVERSITY PRACTICAL EXAMS - DEPARTMENT OF GENERAL MEDICINE

20100006003 PROCEDURAL COMPETENCIES

19100006010 PROCEDURAL COMPETENCIES