CASE PRESENTATION

By:
FIRST ADMISSION
08th August 2019
PRESENTING COMPLAIN
 37 years old male named Mr.Saifullah S/O
Hyder Ali, resident of Pano Akil, cook by
occupation, admitted via OPD on 8th August
2019 with complain of:
 Fever 01 month
HOPC
 According to the statement of patient, he
was in his usual state of health one month
before then he suddenly developed fever
which was high grade in intensity,
intermittent , occurs once in 24 hours, with
no special time of occurrence, relieved by
taking antipyretics, not associated with
cough, sore throat, joint pain, rash or burning
micturition.
 Patient also complains of loss of appetite and

generalized weakness. Also undocumented

hx of weight loss is there.
SYSTEMIC INQUIRY
 No hx of earache or ear discharge.
 No hx of chest pain or shortness of breath.

 No hx of headache, vertigo or vision difficulty.

 No hx of abdominal pain, vomiting or

diarrhea.
 No any hx of burning micturition, hematuria,

dysuria.
 Past HX: No significant past medical hx.
 Past Surgical Hx: No significant past

surgical hx.
 Drug Hx: Patient has taken multiple

treatment since the onset of symptoms. He

had taken antimalarial therapy at first, of
which no documentation is available. Since
last week from the day of admission he has
been taking Cefixime and Azithromycin.
 Transfusion Hx: No any past hx of blood

transfusion
 Personal Hx:
 Appetite-------Decreased
 Sleep------------Normal

 Bowel habits- Regular

 No any drug addiction.

 Family Hx: Married, has two children, lives in joint family

with his brothers and their families. All are in their normal
state of health.

 Social Hx: Belongs to lower class family, source of water is

hand pump, no pet animals at home.
SUMMARY
 Young male patient with previous no known
co morbidity admitted via OPD with
complaint of fever since one month not
associated with cough, sore throat or burning
micturition and h/o generalized weakness,
loss of appetite and weight loss is there.
Patient also reports h/o fatigue and
decreased stamina to do routine activities.
DIFFERENTIAL DIAGNOSIS
GENERAL PHYSICAL EXAMINATION
 An ill looking young male of average height
and thin built, lying over bed, well oriented to
time, place and person with following vitals:
 BP: 60/40 mmHg, No any postural drop in BP was
noted.
 In supine position his BP was 60/40mmHG

 In sitting and standing position his BP was

60/40mmHg
 Pulse: 84 bpm, regular, normal rhythm

 Temp: 100 F

 R/R 22/min
SUB VITALS
 Anemia--------------------------Positive
 Clubbing------------------------Negative

 Koilonychias-------------------Negative

 Leuconychia-------------------Negative

 Palmer Erythema------------Negative

 Cyanosis-----------------------Negative

 Lymph Nodes-----------------Not palpable

 Thyroid-------------------------Normal

 JVP-------------------------------Normal

 Oral cavity---------------------Poor oral hygiene.

EXAMINATION OF PRECORDIUM
 Inspection: Shape normal, no scar, no
pulsations visible over the precordium.

 Palpation: Apex beat palpable in the 5th

intercostal space medial to the mid-clavicular
line. Apex beat normal in character, neither
tapping nor heaving type.

 Auscultation: S1+S2+0, no murmur

audible.
RESPIRATORY EXAMINATION
 Inspection: Respiratory rate 22 b/min, shape
of the chest is normal, respiration is abdomino-
thoracic. No deformity, scar, prominent veins
or pulsation visible. Chest movements are
equal on both sides
 Palpation: Trachea is central, apex beat is

palpable in 5th intercostal space, medial to mid

clavicular line. No tenderness or crepitus.
Movements of chest are equal on both sides.
 Percussion: Upper border of the liver is in 5 th

intercostal space.
 Auscultation: Normal vesicular breathing

sounds are present, vocal resonance normal.

EXAMINATION OF ABDOMEN
 Inspection: Shape of abdomen is normal,
abdomen moving with respiration. Umbilicus
is central and of normal shape. There is no
scar, striae, pulsations or prominent veins.
Hernial orifices intact.
 Palpation: Soft, non tender, liver palpable of

1FB below right costal margin, spleen not

palpable.
 Percussion: tympanic, liver span 14cm

 Auscultation: Bowel sounds audible,

2-4/minute of normal intensity.

 Impression: Liver palpable of 1FB.
NEUROLOGICAL EXAMINATION
 Higher Mental Function: Intact
 Speech: Normal

 Gait: Due to weakness patient is not able to

walk without support.

 SOMI: Negative

 Cranial Nerves: Intact

CASE SUMMARY
 Young male with NKCM admitted via OPD
with C/o Fever since one month, intermittent
type, not associated with cough, sore throat,
burning micturition and h/o loss of appetite,
generalized weakness, fatigue and unable to
perform routine activities.
 O/E: BP: 60/40mmHg with no any postural

drop, Pulse 84 bpm, Temp 100F, R/R 22/min,

anemia+, liver palpable with rest of
examination unremarkable.
COMPLETE BLOOD COUNT
Test 08.08.2019 09.08.2019 11.08.2019
Hemoglobin 8.2g/dl 8.6 g/dl 8.2g/dl
RBC Count - 3.56 mil/cmm 3.27mil/cmm
HCT - 26.2% 26.9%
MCV - 73.6 82.3fl
MCH - 24.7uug 25.1pg
MCHC - 33.6g/dl 30.5g/dl
WBC Count 13200/cmm 16000/cmm 26100/cmm
Neutrophils 44% 50% 57.1%
Lymphocytes 44% 22% 6.1%
Monocytes 10% 26% 36%
Platelets' 44000 45000 62000
PERIPHERAL SMEAR REPORT
09/08/2019

Shows hemolysis,
leucocytosis, no any
immature cell seen and
thrombocytopenia.
Malarial parasite not seen.
BIOCHEMISTRY
Test 08.08.19 09.08.19
Urea 132mg/dl 53mg/dl
Creatinine 2.9mg/dl 1.0mg/dl
Sodium 148mEq/l 143.0mEq/l
Potassium 3.9mEq/l 3.69mEq/l
Chloride 114mEq/l 105.5mEq/l
RBS 104mg/dl
VIRAL SEROLOGY
Test Result
Anti-HCV Positive
HbsAg Negative
HIV Negative
ECG
X-RAY CHEST
ULTRASOUND ABDOMEN
 Liver shows reduced echo pattern, mildly
enlarged.
 Mild splenomegaly noted.

 Gall bladder contain sludge.

 Dilated with thick wall bowl loops noted.

 No evidence of free fluid noted.

 No lesion seen in both kidneys.

 Urinary bladder empty.

MANAGEMENT
 Patient was given only iv fluids and appetizer
after that patient got improvement. His
appetite increased and was able to walk
without any support. Iv steroids(Decadran
2mlx bd) was given but it did not improve his
blood pressure. On 11th August 2011, patient
was discharged on request on appetizer,
ORS.
 ACTH and cortisol were sent in early

morning along with blood culture and CBC

with peripheral smear and was advised to
follow up in Ward after Eid with these reports.
2ND ADMISSION
19th August 2019
PRESENTING COMPLAIN
 Patient was readmitted on 19th August 2019,
via ER with c/o:
 Loss Of consciousness------ Last Night
HOPC
 According to the statement of patient’s
attendant he was in his usual state of health
after getting DOR, he was getting better but
since last night he suddenly developed loss
of consciousness not associated with fever,
vomiting, headache or fits.
ON EXAMINATION
 Patient was unconscious with following vitals:
 BP-Not Recordable
 Pulse-Not palpable
 Temp-98F
 R/R 30/min
 Sub vitals- Anemia+, Jaundice+, Edema++, Clubbing and
Kolonychia negative
 RBS was low.
 CNS
 GCS E1 V1 M1=3/15
 Pupils-BERL
 Planters-Equivocal
 CVS- S1+S2+0(No any murmurs)
 Chest B/l Clear with NVB
 Abdomen-Soft, Non tender, no visceromegaly palpable.
EMERGENCY MANAGEMENT
 Double iv line was maintained, Iv fluids, inj.
25% DW 4amp and inj. Hydrocortisone
250mg iv x stat given. Within few minutes
patient got his consciousness back. After 30
minutes of emergency treatment patient was
fully oriented and has following vitals:
 BP 60/40mmHg
 Pulse 90 bpm
 Temp 98F
 R/R 22/min
NEXT DAY
On next day patient’s yellow discoloration of eyes increased as
compared to earlier. And had 2-3 episodes of hypoglycemia in last
24 hours.
New signs & symptoms
Patient was drowsy but oriented to time person and place. Vitals
were same.
Patient has developed non blenching macular rash all over trunk.
Limbs, neck and face were spared.
Also bony tenderness was present.
Respiratory examination- Patient had developed dry cough,
chest was clear with NVB sounds.
Abdomen-Mild tenderness at right hypochondrial region, no
visceromegaly palpable.
CNS- Drowsy, GCS E3V5M6-14/15
Planters B/l down
SOMI Negative
Pupils BERL
BLOOD CULTURE
 No growth after 5 days.
CT SCAN ABDOMEN WITH CONTRAST
CT SCAN ABDOMEN WITH CONTRAST
 Findings:
 There is evidence of collapsed & thickened wall bowel loops
showing poor post contrast enhancement.
 Superior mesenteric artery is normal, however superior
mesenteric vein is not properly opacified.
 Normal both adrenal glands. No focal lesion seen.
 Moderate ascites seen in peritoneal cavity.
 Bilateral mild pleural effusion more marked on right side.
 Liver is normal in size(15.2cm) containing no mass or cyst.
 Spleen is normal in size (10.1cm) containing no mass or cyst.
 Portal vein is not dilated at porta hepatis.
 Pancreas is normal in size with containing no mass or cyst.
 Gall bladder is normal in size with thin walls, containing no mass, cyst
or stone.
 Common bile duct is normal in diameter.
 No para-aortic lymphadenopathy seen.
 Both kidneys are normal in size containing no mass, cyst or stone.
 NO evidence of hydronephrosis identified.
 Urinary bladder is mildly filled with thin walls, however no cyst or stone.
ECHOCARDIOGRAPHY
 Normal size LV with normal wall thickness.
 No SWMA

 Good LV Systolic Function

 LVEF 68%
X-RAY CHEST
ACTH AND CORTISOL LEVELS AT
08:00 AM
Test Result Ranges
Plasma ACTH 67.5pg/ml Male=ND-46.o
pg/ml
Serum Cortisol 2.60 ug/dl AM-4.3-22.4
PM-3.09-16.66
BLOOD BIOCHEMISTRY
Test Result
Urea 68mg/dl
Creatinine 1.0mg/dl
Sodium 138.0mEq/l
Potassium 3.94mEq/l
Chloride 102.5mEq/l
Bicarbonate 21mEq/l
LIVER FUNCTION TEST
Test Result
Bilirubin(T) 10.0mg/dl
Bilirubin(D) 5.0mg/dl
SGPT(ALT) 50u/l
Alkaline Phosphatase 720u/l
OTHER TESTS
Test Result Normal range
LDH 7358u/l 105-315
Retic Count 10.0% 0.5-2
OPEN FOR DISCUSSION
DIAGNOSIS
 Acute Myeloid Leukemia with adrenal crisis.
Thank You!!!