hospital presentation
Transcript: latifa saeed alkhatri 201410227 case presentation patient information pateint details Name : A. I Age : 60 yo Gender : male weight : 134 kg height : 138cm BmI : 40 BMI BMI Chief complaint: Chief complaint A.I come to hospital and was suffering from diffrent conditions severe back pain body pain joint pain palpitation fever Dizzness cough heart burn pain both feet left dorsal pain bilateral leg pain burning sensation more on right one and started form ankle to the knee pallor sluggish capillary refilling dorsalis pedis is not palpable severe back pain body pain joint pa... dorsalis pedis dorsalis pedis patient history patient history social history social history Marrid , and he have 3 children 1 1 Smoker : 20 sticks per day 2 2 Works : he is a teacher in school 3 3 family history Family history Father deied of stroke heart attack aage 59 years hypertension smoker father father alive artrial fibrillation heart failure Mother Mother Healthy siblings siblings siblings history of present illnest History of present illness chronic ischemia chronic ischemia both lower limbs since 2007 , patient came to Ajman specialty hospital suffreing from : leg pain , and burning senstion and swelling started from ankle up to the knee also pain in both feet Peripheral vascular disease commonly affects the arteries supplying the leg and is mostly caused by atherosclerosis. Atherosclerotic plaque buildup in the peripheral arteries • Narrows blood vessel lumen and decreases flow to the muscle • Results in pain of the muscle group distal to the lesion chronic lower limb ischemia • Smoking • Diabetes • Hypertension • Hyperlipidemia • Obesity • History of coronary artery disease, stroke, or vascular disease Risk factors : Chronic back pain chronic back pain since 2007 , the Mr A. I suffering from chronic recurrent lower back pain with radiation to the right lower limb assosicated with parasthesia he has history of chronic back pain , and MRI shows lumber disc prolapsed L5-S1 MRI L5 S1 Degenrative disc lesion at L5-S1 abutting both S1 nerve roots , more on the right side . Bilateral mild L3-4 facet joints arthropathies . MRI Normal MRI : S1 L5 Anatomy the lumber spine ( lower back ) consists of five vertebrae numbbered L1 to L5 these vertebrae are attached to the sacrum at the lower end of the spine Anatomy prolapse of the L5-S1 disc will affect the S1 nerve root persistent or fluctuating last longer then 3 months causes : Ankylosing spondylitis • Neoplasms • Infections( TB, Herpes, osteomyelitis) • Atherosclerosis • Visceral pain Chronic back pain : chronic sinusitis chronic sinusitis (allergic) : "2013" PNS (water view ) Mild to moderate mucosal hypertrophy of both maxillary sinuses are noted more evidant on the left side suggestive of sinusitis for clinical correlation . Bilateral Mucosal hypertrophy of inferior nasal turbinate is also notes with evidence of nasal septum deviation to the left . There is no evidence of mucosal thinking opacification or fluid collection in thee other par anasal sinuses for osteomeatal channels patency , further CT evaluation is recommended It is the sinus infection lasting for months or years. signs and symptoms : Pain, tenderness and swelling around the eyes, cheeks, nose or forehead Nasal obstruction or congestion Ear pain Aching in your upper jaw and teeth Cough that might worsen at night Sore throat Bad breath (halitosis) Fatigue or irritability Nausea Chronic sinusitis hyperlipidemia Others Others past medical history past medical history Hospitalization and surgical not recorded Hospitalization and surgical not recorded 2009 to 2017 Lab tests Lab tests 2009 2009 Tumor markers : normal TSH test ( Thyroid - stimulating hormone ) : normal 2010 Antibiotic sensitivity : pencilin - erythromycin resistance CRP : negative Glucose RBC : normal 2010 bacteria type Antibiotic resistance occurs when bacteria change in response to the use of these medicines. Bacteria, not humans or animals, become antibiotic-resistant. These bacteria may infect humans and animals, and the infections they cause are harder to treat than those caused by non-resistant bacteria. Antibiotic resistance leads to higher medical costs, prolonged hospital stays, and increased mortality. AB resistant C-reactive protein test is a substance produced by liver in response to inflammation it's measure the ammount of protein called c-reactive protein in the blood it's mesures general levels of inflammation in the body CRP test 2011 CRP tset : positive (12mg/L) ESR test ( Erythrycin sedimenation test ) : Normal Rheumatoid factor : Negative Urine analysis : Every thing was normal Renal Function ( urea , creatinine .. etc ) : Normal HBA1C test : Not diabetic Vit B12 : Normal 25 hydroxy (OH) Vit D : Deficency stool analysis : Every thing was normal 2011 it's an autoantibody that is directed against organism's own tissues , most relevant in rhematoid arthritis Rheumatoid factors test 2012 CRP test : Negative 2012 2013 lipid test : every thing was
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