Case presentation

DR Naqeebullah,
PGR,
Medicine Unit IV.
Patient Ghulam mohammad 45 years old, truck driver, resident of
khuchlak ,with no known co-morbidities,naswar and marijuana addict
presented with
multiple swelling in body…….2months
fever………………2months

HOPI; -
A/C to patient he was in his usual state of health 2 months back
then he developed swelling in neck,multiple,notice by patient
himself,gradual in onset, gradually increasing in size and
numbers,painless,mobile,with no discharge and skin changes. He
also noticed similar swelling in axilla and groin region over time.
He also complain of fever from last 2months,gradual in onset,
high grade,non documented,intermittent,no rigors and chills but
with night sweats, no specific time of occurance,no aggrevating
factors relived by taking Panadol tablet.
fever is associated with vomiting 3-4 episodes,watery
,associated with food intake,no blood in it.there is history
of recurrent sore throat but no history of ear
discharge,cough,expectoration,abdominal pain ,losse
motion,and urinary complain.he also complain of itchy rash
2 months back,acute in onset,maculopapular,all over the
body,no discharge from it, relived spontaneously in 2
weeks.there is no tb contact history and animal contact
history.
There is no history of headache,blackouts,fits,visual loss
,diplopia,numbness,hearing problems.
There is no hx of dizziness,sob,orthopnea,pnd,pain in legs and leg
swelling.
There is no hx of mouth ulcer,swallowing difficulties,pain during
swallowing, change in voice,distention,jaundice and loose motion or
constipation.
There is no hx of flank pain,blood in urine,periorbital
puffiness,freguency,frothy urine and burning micturition.
There is no hx of bruising,bleeding from any site,easy fatiguability
There is no history of joint pain,stiffness,swelling,restriction of
movements.
There is no hx of heat or cold intolerance,abnormal movements of
hands,alteredhabits,sweating,palpitation,polyuria,polydipsia,polypha
gia, skin colour changes,dizziness,and purple striae.
There is no past history of tb, hepatitis,thyroid disease,any drug intake
unpasteurized milk intake,
There is no history of tb ,IHD,HTN.Asthma,jaundice and malignancy in family.
Married with 7 kids,all are healthy.
sleep is disturbed,naswar addict from childhood,marijuana addict from 10
years,weight loss but not documented.hx of unprotective extramarital sexual
contact 10 years back.
he lives in own muddy house ,use tap water.all basic facility available.
There is no drug allergy history.
No any special diet restriction or supplementation,use vegetables ,meats and
fruits in week.
On examination an ill looking middle age man lying on bed comfortably
well oriented to time place and person,cannulated on his right hand
with following vitals,

B.P 120/70 mmhg JAUNDICE = -VE

Pulse 85/min R PALLOR = -VE
Temp 98 CYANOSIS = -VE
R/R 21/MIN CLUBBING = -VE
KOILONYCHIA = -VE
LYMPHADENOPATHY = +
generalized lymphadenopathy largest on in left inguinal
regions measuring 8x6cm,rubbery,nontender,nonadherent to skin and
underlying fascia,non discharging. No thyromegaly ,no sternal
tenderness.
 Git Examination.
 Orodental hygiene is satisfactory. No ulcer,gum hypertropy or enlarged tonsils.
 No tenderness on superficial and deep palpation.

 Spleen is palpable 1.5cm below LCM ,firm in consistency.regular margin ,smooth surface.
 Liver is palpable 3cm below RCM,firm in consistency,smooth surface,regular ,margin, with total liver
span of 13cm.
 Kidneys are not ballotable.
 No shifting dullness
 Gut sound audible with normal frequency.no hepatic bruit or splenic rub.
 RESPIRATORY SYSTEM EXAMIATION
 no chest deformity,scarmark,no tenderness, chest expansion is 3cm,Trachea centrally placed.
 Percussion note is resonent ,normal vescicular breath sounds , normal vocal resonance.
 No added sounds.
 CVS Examination.
 Apex Beat is normal in character and palpable in 5th intercostal space medial
to the mid clavicular line. No parasternal heave or thrill…….
 First and second heart sounds are audible and normal in character. No added
sounds or murmurs.
 RUL LUL RLL LLL

 CNS EXAMINATION
Bulk Normal Normal Normal Normal
GCS =15/15
Tone Normal Normal Normal Normal
Signs of meningeal irritation absent.
Cranial nerves are intact. Power 5/5 5/5 5/5 5/5
Sensory system intact.
Pupils = round and reactive to Reflexes Normal Normal Normal Normal
light.
Normal joint position, vibration, two point discrimination Plantars Down Down
No cerebellar signs present. going going
NO PROXIMAL MYOPATHY.
Differential Diagnosis:
Lymphoproliferative disorder
Myeloproliferative disorder
HIV INFECTION
INVESTIGATIONS.
CBC:

Hb 14.6g/dl

Red cell 5.26 [10~6/ul]

HCT 42 %

MCV 80fl

MCHC 36.8 g/dl

PLT 221(10^3/ul)

TLC 9.5(10^3/ul)

Neutrophils 70%

Lymphocytes 17.8%

Monocytes 06 %
PHERPHRAL SMEAR

 RBCS=NORMAL MORPOLOGY.NO IMMATURE CELLS

 RETICS=0.7%
 WBCS=NORMAL MORPHOLOGY,NO IMMATURE CELLS
 PLATELETS=ADEQUATE
 CRP=92mg/dl
Test Result

LDH 1266U/L

Urea 28mg/dl

Creatinine 1.1 mg/dl

Serum SODIUM 134 mg/dl

Serum POTASSIUN 3.1mg/dl

Liver funtion test

 Total bilirubin=0.7mg/dl
 ALT=27U/L
 Alkaline phosphatase=816U/L
 Gama GT 99U/L
TSH=2.49uUI/ml
HIV Ag/Ab Elisa=negative
Ultrasound abdomen Report

NOT DONE

CHEST XRAY
NOT DONE
Provisional DIAGNOSIS

LYMPHOMA
PLAN:
 Chest x-ray, ultrasond
abdomen
 excisional lymph node biopsy
Bone marrow trephine