40 YR OLD FEMALE WITH WATERING AND SWELLING OF LEFT EYE

202420242 rajitha
CASE HISTORY AND CLINICAL FINDINGS
PATIENT PRESENTED WITH C/O WATERING FROM LEFT EYE SINCE 2 YEARS
SWELLING OF LEFT EYE SINCE 2 YEARS
HOPI -
PATIENT WAS APPARENTLY ASYMPTOMATIC 2 YEARS BACK THEN SHE DEVELOPED
WATERING AND SWELLING OF LEFT EYE FOR WHICH SHE TOOK TREATMENT AND GOT
RELIEVED AND DEVELOPED SWELLING AGAIN 3 DAYS BACK WHICH IS INSIDIOUS IN ONSET
SUDDEN IN PROGRESSION
HISTORY OF PAST ILLNESS
K/C/O EPILEPSY 1 YEAR BACK
N/K/C/O HTN DM TRAUMA CVA CAD THYROID
H/O DIALYSIS 2 YEARS BACK
ON EXAMINATION
PATIENT CONCIOUS COHERENT COOPERATIVE
TEMP 97.3F
PULSE 96 BPM
RR 20/MIN
BP 140/100mmHg
SPO2 98%
PALLOR PRESENT
NO ICTERUS CYANOSIS LYMPHADENOPATHY CLUBBING
SYSTEMIC EXAMINATION:
CVS:S1S2 HEARD , NO MURMURS.
RS :BAE NORMAL, NVBS
CNS :NO FOCAL NEUROLOGIC DEFICIT
LEVEL OF CONSIOUSNESS: CONCIOUS
CRANIAL NERVES, MOTOR NERVES, SENSORYSYSTEM NORMAL
SPEECH : NORMAL
NO NECK STIFFNESS
NO KERNIGS SIGN
P/A: ON EXAMINATION
SHAPE: OBESE
INSPECTION-
UMBILICUC IS CENTRAL AND INVERTED
NO SCARS, NO SINUSES, NO ENGORGED VEINS
ALL QUADRANTS OF ABDOMEN MOVE EQUALLY WITH RESPIRATION
NO VISIBLE PULSATION
NO VISIBLE PERISTALSIS
PALPATION:
SOFT
NO LOCAL RAISE OF TEMPERATURE
TENDERNESS PRESENT IN EPIGASTRIUM
RIGHT HYPOCHONDRIUM
NO GUARDING, NO RIGIDITY
NO SHIFTING DULLNESS AND NO FLUID THRILL
BOWEL SOUNDS PRESENT
DIALYSIS DONE ON 14/5/24
 14/5/24
 17/5/24
 19/5/24
INVESTIGATION
NameValueNameValueAnti HCV Antibodies - RAPID08-05-2024 05:34:PMNon Reactive HBsAg-
RAPID08-05-2024 05:34:PMNegative COMPLETE BLOOD PICTURE (CBP) 08-05-2024 09:58:PM
HAEMOGLOBIN6.7 gm/dlTOTAL COUNT7600 cells/cummNEUTROPHILS74 %LYMPHOCYTES20
%EOSINOPHILS02 %MONOCYTES04 %BASOPHILS00 %PLATELET
COUNT1.1SMEARNormocytic normochromic anemia with thrombocytopeniaLIVER FUNCTION
TEST (LFT) 09-05-2024 12:52:PM Total Bilurubin0.45 mg/dlDirect Bilurubin0.17 mg/dlSGOT(AST)13
IU/LSGPT(ALT)10 IU/LALKALINE PHOSPHATASE92 IU/LTOTAL PROTEINS7.2
gm/dlALBUMIN3.66 gm/dlA/G RATIO1.03POST LUNCH BLOOD SUGAR09-05-2024 12:52:PM126
mg/dlRFT 09-05-2024 12:52:PM UREA99 mg/dlCREATININE7.9 mg/dlURIC ACID6.4
mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS6.3 mg/dlSODIUM135 mmol/LPOTASSIUM4.6
mmol/L.CHLORIDE103 mmol/LCOMPLETE BLOOD PICTURE (CBP) 10-05-2024 01:21:PM
HAEMOGLOBIN6.1 gm/dlTOTAL COUNT4600 cells/cummNEUTROPHILS64 %LYMPHOCYTES25
%EOSINOPHILS01 %MONOCYTES10 %BASOPHILS00 %PLATELET
COUNT1.20SMEARNormocytic normochromic anemia with thrombocytopeniaCOMPLETE URINE
EXAMINATION (CUE) 12-05-2024 06:16:AM COLOURPale
yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+++SUGARNilBILE
SALTSNilBILE PIGMENTSNilPUS CELLS3-5EPITHELIAL CELLS2-4RED BLOOD
CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilBLOOD UREA12-
05-2024 08:55:AM83 mg/dlSERUM CREATININE12-05-2024 08:55:AM7.9 mg/dlRFT 13-05-2024
10:41:PM UREA72 mg/dlCREATININE6.9 mg/dlURIC ACID3.4 mmol/LCALCIUM10.2
mg/dlPHOSPHOROUS2.3 mg/dlSODIUM136 mmol/LPOTASSIUM4.8 mmol/L.CHLORIDE104
mmol/LCOMPLETE BLOOD PICTURE (CBP) 13-05-2024 10:41:PM HAEMOGLOBIN6.0
gm/dlTOTAL COUNT5400 cells/cummNEUTROPHILS73 %LYMPHOCYTES21 %EOSINOPHILS01
%MONOCYTES05 %BASOPHILS00 %PLATELET COUNT1.5SMEARNormocytic normochromic
anemiaRFT 15-05-2024 12:42:AM UREA88 mg/dlCREATININE7.9 mg/dlURIC ACID8.0
mmol/LCALCIUM10.0 mg/dlPHOSPHOROUS7.4 mg/dlSODIUM137 mmol/LPOTASSIUM4.6
mmol/L.CHLORIDE106 mmol/L
USG:
E/O 13X13mm HYPERECHOIC LESION NOTED IN SEGMENT 7 OF LIVER- LIKELY
HEMANGIOMA OF LIVER
B/L KIDNEYS SHOW GRADE 2 TO 3 RPD CHANGES
DIAGNOSIS
CHRONIC RENAL FAILURE
CHRONIC DACROCYSTITIS
K/C/O EPILEPSY
TREATMENT GIVEN
FLUID RESTRICTION <1.5L/DAY
SALT RESTRICTION <2G/DAY
INJ MONOCEF 1GM/IV/BD
INJ PAN 40MG IV/OD/8AM
INJ EPO 4000 IU/SC/ONCE WEEKLY
TAB CHYMEROL FORTE /PO/TID
TAB LEVIPIL 500MG PO/OD
TAB OROFER XT PO/OD
MONITOR VITALS 4TH HOURLY
ADVICE AT DISCHARGE
FLUID RESTRICTION <1.5L/DAY
SALT RESTRICTION <2G/DAY
INJ EPO 4000 IU/SC/ONCE WEEKLY
TAB TAXIM O 200MG PO/BD X 5 DAYS
TAB PAN 40MG PO/OD /BF 8A.M X5DAYS
TAB CHYMEROL FORTE /PO/TID
TAB LEVIPIL 500MG PO/OD
TAB OROFER XT PO/OD


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