بسم هللا الرحمن الرحيم

Case Presentation

Supervised by :

Dr. Arwa M. Fawzi

Presented by :

May AbdulRahman

Saraa Ahmed

Name : سكته محمد ابراهيم

Age : 60 years.

Occupation: house wife .

Residence : حي النهروان

Marital state : Widow with 6 sibling .

D.O.A : 17/3/2013..

D.O.E : 20/3/2013..

Chief complaint :

Frequent loose bowel motion for 10 days

before admission .

History of present illness :

The patient was presented 12 days ago with

gradual onset of mild central abdominal pain

colicky in nature came in attacks ,each attack

last for 15 minutes ,relieved by passing motion

frequent loose bowel motion ,watery , bad

odor ,moderate amount about 10_15 times

/day it was yellowish,there was no tenesmus

and became associated with high grade fever

that was continuous all over the day and

relieved only by antipyretic, not associated

with chills or rigor .

poor appetite with early satiety ,prevous

attacks of dysphagia & odynophagia,

releaved now. she had attacks of heart burn

relieve by antacid.

No nausea or vomiting

Urinary system: decrease in urine out put

and became dark in colour, no loin pain.

Respiratory system :attacks of dyspnea from

time to time ,but became more prominent in

the last 3 months, not related to exertion or

sleep. Attacks of cough (some times

productive of whitish sputum) no chest pain.

Cardiovascular system: attacks of palpitaion,

came suddenly and resolve suddenly last for

15 m, not related to exertion , no orthopnea,

no PND, no leg edema ,no syncope.

CNS : not remarkable

Muscolskeletal : Early morning stiffness last

less than half hour, Arthralgia mainly in ankle ,

wrist and elbow , No joints swelling ,

generalized fatigability.

Difficulty to stand from sitting position

before 30 y , she had pain ,swelling and

redness at the tip of the middle finger ,and

then started to involve the tips of the other

fingers of both hands and toes , also she had

dysphagia and odynophagia, she had

progressively increasing mottling rash in the

face.

she is Hypertensive for 15 years.

In the last 4 years, she had recurrent attacks

of mild diarrhea ( about 3 times/day in form

of steatorrhea ) and last few days and stop

by medication and some time change to

constipation.

Epistaxis before 3 years .that was not

continuous last for 3 days ,stopped

spontaneously.

2 years ago she had frequent attacks of

palpitation diagnosed as SVT.

before 1 year , she develop sever SOB that

was of sudden onset that last for 1 weak and

receive inhalers(bronchodilators, and

steroid) for one month.

Amputation of the left big toe at 1998 ..

Cataract surgery for both eyes before 8

months .

Prednisolone : for 30 year

10mg /day

Losartan 50mg/day.

Verapamil 40mg/day.

Amiodaron 200mg /day.

Aspirin 100mg/day

Folic acid and ferrus fumarate

Omeprazole ( on need )

No drug allergy .

There is family HX of hypertension , diabetes mellitus.

Poor socioeconomic state , crowding index

is 4.

No animals in the house , no smoking .

Suggest the diagnosis?

What is the cause of recurrent diarrhea?

How you explain the amputation?

Middle age female

lying in bed conscious

alert,

thin body build,

she is dyspneac not

cyanosed

Severely anemic.

Firely red tong

telangiectasia all over

the face with small

mouth and pinch beak

like nose .

Both hands show flexion contractures of the

fingers with destruction of the nails and loss of

the tips of the fingers , the skin overlying it is

tough inelastic ,and it is pale, with multiple

telangiectasia and bruises at site of cannula

The legs show shiny pale skin, bruises on the

right shin, no leg edema or calf tenderness

,there is loss of part of the digits in the 4th and

5th right toes, amputated left big toe ,and

inflamed 2nd left toe.

Pulse was 70 bpm .

Blood pressure 140/80 .

respiratory rate : 20

Temperature : 37 C .

Inspection shows :

* mild symetrical distended abdomen ,move

freely with respiration ,no dilated viens no

previous scar, with inverted central umbilicus .

Palpation shows :

Soft abdomen, not tender, no superficial mass

,no palpable deep organ .

percussion was tympanatic

Auscultation shows positive bowel sound

Inspection:

Barrel shape chest ,with multiple

telangiectasia, in the center of the upper part,

there is no scar

palpation : trachea is central no site of

tenderness , tactile vocal fremitus was

symmetrical in both side.

percussion was resonant

Auscultation : vesicular breathing with course

crepitation scattered all over the chest more

prominent in the bases

Palpation apex beat deviated lateral to MCL

with no special character ,no thrills ,no

parasternal heave

Auscultation show loud S1 and normal S2

with mid systolic murmur grade2 ,no

radiation ,maximal intensity in the apex .

Higher brain function and cranial nerves

examination was unremarkable

Motor examination of the upper limbs and

lower limbs was normal apart from the fixed

deformity of the distal parts of the limbs and

Signs of proximal myopathy

sensory examination : was normal

How you explain the anemia?

Anemia of chronic disease

Malabsorption syndrome(dimorphic aemia)

Uremia .

What are the GIT complications of this

disease?

Reflux ,erosive esophagitis,

Stomach involvement: outlet obstruction and

watermelon stomach

Small intestine: malabsorption, intermittent

bloating ,pain or constipation.

Large intestine: pseudo obstruction.

Mention the cardiac complication of this

disease?

Pericarditis

Heart failure

Arrhythmias

Cardiomyopathy

Systemic or pulmonary hypertension

A-v block

Possible respiratory complication?

Fibrosing alveolitis

Pulmonary hypertension

Bronchiectesis

Aspiration pneumonia

Cause of hypertension?

Renal involvment.

Chronic use of steroid.

Atherosclerosis.

Other renal complication?

Hypertensive renal crisis.

Renal artery stenosis

Causes of proximal myopathy?

Non progressive myopathy.

steroid

Is there any risk of malignancy in the future?

Copmlete

blood

Picture

General

Urine examination

RFT (1ST)

2ND RFT &

Serum electrolyte

3RD RFT

&serum electrolyte

US of the abdomen

Echocardiograph

I.V fluid ringer lactate 4 unit\day

Metronidazole I.V 3*1

cefotaxime injection 1*2

paracetamol on need

vancoltel tablet 2*3

antispasmin tab 1*3

B12 ampoule IM .

Ciprodar 500mg 1*2

For skin ulceration high Dose of AB for longer

period .

for Raynaud’s phenomena Calcium

antagonist, for sever digital ischemia

,intermittent infusion of Epoprostenol may

be helpful.

Steroid and cytotoxic drugs indicated only in

myositis and alveoltis.

No agent has been shown to improve or

arrest skin changes

Thank you

for attention