Case

Presentation

Dr. ARSALA KHAN

PGR1

Medicine unit 4 SPH

HISTORY
70 Year old Mohammad Baraan resident of
Kuchlaak know Hypertensive & Type-II
Diabetes Mellitus non complaints to treatment
was admitted on 26 August through OPD with
presenting complaints of:

1. Generalized Bony Pain - 6months

2. Increased frequency of Micturition –
5months
3. Fever – 1month
 According to patient attendant he was in his usual state of
health 6 month back when he gave history of Generalized Bony
pain initially started from lower limbs gradual in onset which is
progressive then involving lower back ,shoulder joint,chest &
whole body on severity scale pain was 7/10 aggravated by
walking & movement relieved by medications due to pain now
patient was bedridden for last 3months associated with weight
loss not documented but family member noticed loosening of his
clothes. Patients also complains increased frequency of urine
was insidious in onset n gradual progressive up to 13 to 15
times a day without increasing water intake and inability to hold
urine, once the urge initiate few occasion he had soiled his
clothes due to inability to hold.
Fever was gradual in onset, low grade not documented more at
morning & Night not associated with rigor & chills there was no
aggravating factor while fever got relieved by antipyretic. fever
is associated with nausea and anorexia. No history sore throat
burning micturation ear discharge & flu like symptoms
There is also history of Fatigue & excerational dysnea gradual
in onset and progressive No Hx of cough, sputum, ,
Tachypnoae, hoarseness, wheezing , cynosis, orthopnea, PND,
. mouth ulcers
No Hx of jaundice, vomiting, heart burn, heamatemesis,
.melena
No hx of mucosal bleed bleeding tendency blurring of vision
vertigo headache
o No Hx of iv drug abuse, tattoo or recent travel.
o sleep is disturbed from last 2 years.
o Appetite is decreased and complains of constipation.
o No known drug allergies and addiction
o Once Hx of blood transfusion.
o Siblings are healthy, TB contact +ve, family Hx of HTN, DM,
no IHD, vascular diseases , hepatitis, or any other
malignancy.
o Patients belongs to low socioeconomic status, lives in a
cemented home with all basic facilities of life available, drinks
tap water, sanitary conditions are satisfactory .
EXAMINATION
 An ill looking emaciated old aged male lying on bed well oriented time place
and person , catheterized, cannulated in left hand well cooperative towards
examination, well demarcated lesion on the inner canthus of the left eye
black in colour 2cm in size, Dermatologist after examine diagnosed it
pigmented Basal Cell Carcinoma following vitals:

o Bp:110/60 mmHg o Jaundice –ve

o Pulse:73 beats/min o Anemia +ve
o R/R:20 breaths/min o Koilonykia –ve
o Temp: afebrile o Clubbing +ve
o Spo2:95% at room air o Edema +ve
o GCS:15/15 o Lymph nodes palpable 1on ant cervical 3
o Oral hygiene not satisfactory small on inguinal region 1.5cm mobile non
adherent firm in consistency & not
o Thyroid examination normal
discharging.
 Soft, non tender, no viseromegaly appreciated, fluid thrill -, gut sounds
:ABDOMEN audible
DRE :Size of prostrate is not appreciated surface is smooth consistency
is hard separate from rectal mucosa anal tone is increase inspection of
finger there is no blood n melana
On the DRE Examination I found ist degree pressure sore on the coccyx
.region

Trachea central,normal chest expansion 3cm,

:RESPIRATORY normal vasicular breathing, breath sound is dec
on rt lower lobe of lung ,increased vocal
.resonance Percussion note is dull on that area
with no added sounds

:CARDIOVASCULAR
Apex beat is on 5th ICS 9cm from left sternal boarder there
is no parasternal hive and thrill S1+S2 heard in all four
cardiac areas with no added murmurs and no signs of
cardiac failure
 :CNS

GCS: 15/15
Pupils reactive to light bilaterally
Planters down going bilaterally
No neck rigidity

RUL RLL LUL LLL

BULK Dec Dec Dec Dec

TONE N N N N

POWER 5/5 5/5 5/5 5/5

REFLEXES Diminished Diminished Diminished Diminished

Cerebeller signs: intact, unable to asses gate because patient was unable to
walk.
Cranial nerves:
All cranial nerves are intact
DIFFERENTIAL DIAGNOSIS:

o Multiple Myeloma
o Disseminated Tuberculosis
o Malignancy
o Hyper parathyroid
INVESTIGATIONS
 CBC:
Test name Result

Hb 5.6

W.B.C 11

Neutophils 84%

Lymphocytes 15%

Eosinophils 0.5%

Monocytes 0.4%

Platelets 369,ooo

P Smear HYPOCHROMIC MICROCYTIC ANEMIA

GLUCOSE :

Hba1c: 11.7%

Random : 306 mg/dl

TOTOTAL BILIRUBIN 0.8mg/dl 0.1-1.0mg/dl
ALT 11U/L 40U/L
ALKALINE PHOSPHATE 3297U/L 275U/L
GGT 38U/L 46U/L
SKELETON SURVEY
 Urine Analysis

Quantity 30ml
PH 6.0
Albumin ++
Sugar ++
Pus cell 15
Specific Gravity 1.025
Red cell 20/HPF
Mucus thread +
o UREA : 33mg/dl
o CREATININE :1.9mg/dl
o Serum Calcium :8.1mg/dl
o Serum Albumin 3.5 G/dl
Ultrasound Abdomen Report
Normal abdominal scan
Urinary bladder is empty
No Ascites seen
 TOTAL PSA
Test Name Results Normal range

PSA 100ng/ml 0-6.5

– CECT Abdomen
– Liver is enlarged in size. Calcific focus is appreciated
at the periphery along the capsule suggestive
granuloma
– There is subtle focal low attenuation area are noted
in left hepatic lobe ,suspicious enhancing lesion
appreciated in portal phase in segment 8
– Calcific focus is seen in the spleen
– Lymph nodes at para aortic n right iliac level
1.8x1.6cm suggestive of lymphadenopathy
– Prostate is mildly enlarged 3.6x3.3x4.0cm weight
27gram there is no irregularity is noted
– O.A changes are seen in bony spine
– All the visualized bone show lytic lesions
PLAN:

o ESR
o C-REACTIVE PROTEIN
o SERUM PROTEIN ELECTROPHOROSIS
o Excisional Biopsy of Lymphnode/AFB