1601006053 LONG CASE

 

1601006053



 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

65 year old female with fever , generalised abdominal pain and loose stools.

A 65 yr old woman, from narketpally who is a house wife ,came to the hospital with chief complaints of fever with chills since 8 days and pain abdomen since 6 days, loose stools since 6 days.

*HISTORY OF PRESENT ILLNESS-

The patient was apprently asymptomatic one week back and then she developed

Fever-which was sudden in onset,high grade,associated with chills and rigor,relieved on medication

Lower abdominal pain-sudden in onset,continuous cramping like/dull aching and aggravated on food intake

Vomiting-2-3 episodes /day,non-bilious,non-projectile,watery consistency

Loose stools-multiple episodes in large volume, watery,non blood or mucous in stools

History of burning micturition since 4 days-high coloured urine and no hematuria

*PAST HISTORY-

History of diabetes type 2 since 10 years and on medication

History of hypertension since 10 years and on medication

No history of epilepsy ,asthma, seizures

*TREATMENT HISTORY-

Diabetes-metformin 500 mg+idalgliptin 500 mg

Hypertension-telmisartan-40 mg

*PERSONAL HISTORY-

Diet-mixed

Appetite-decreased

Bowel movements-irregular

Bladder-incontinence with burning micturition

No known allergies

No addictions

*FAMILY HISTORY-not significant


*GENERAL EXAMINATION-

Patient is conscious,coherent and cooperative

Well oriented to time,place and person,moderately built and moderately nourished

Pallor-present

Icterus-absent

Clubbing-absent

Cyanosis-absent

Koilonychia-absent

Lymphadenopathy-absent

Edema-facial puffiness present

VITALS-

Temperature-98.5 F,afebrile

Blood pressure-120/90mm Hg

Pulse-110/min

RR-26cpm

SpO2-96% at room air

*SYSTEMIC EXAMINATION-

*ABDOMEN-

Inspection-

Shape-distended,flanks full





Umbilicus-inverted

Movements with respiration -equal in all quadrants

Skin over abdomen-multiple vertical and horizontal striae present

Palpation-

Tenderness-diffuse in right iliac fossa

Liver impalpable

Gall bladder impalpable

Spleen impalpable

Percussion-

Shifting dullness not present

Fluid thrill not present

Auscultation-

Bowel sounds heard

OTHER SYSTEM EXAMINATION-


CVS-S1,S2 heard

Apical impulse 5th intercostal space,2cms lateral to midclavicular line

No murmurs

RESPIRATORY SYSTEM-

Normal vesicular breath sounds heard

Bronchial breath sounds heard

Trachea midline

CNS-

Cranial nerve examination:normal

Gait:normal 

Reflexes:normal

CHEST XRAY


    HEMOGRAM-

         

         RENAL FUNCTION TEST-

         
        COMPLETE URINE EXAMINATION-

         FASTING BLOOD SUGAR-
         
         USG REPORT-
         
          COMPLETE URINE EXAMINATION-
        
          Hb1Ac-


INVESTIGATIONS-

Stool examination and culture

Sigmoidoscopy/colonoscopy

Urine analysis

RENAL FUNCTION TESTS-

Increased serum creatinine levels

Decreased leucocytes


URINE EXAMINATION-

Increased pus cells in urine

*PROVISIONAL DIAGNOSIS-

Acute gastroenteritis 


Comments

Post a Comment

Popular posts from this blog

  2K16 BATCH UNIVERSITY PRACTICAL EXAMS    DEPARTMENT OF GENERAL MEDICINE   DATE: 26.04.2021 (MONDAY) S. NO HALLTICKET NO CASE BLOG LINKS  CASE PRESENTATION VIDEO LINKS      1 1601006001 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-long-case-april-23-2021-hall.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006001-short-case-april-25-2021.html https://youtu.be/9xE26ZkzqDg 2 1601006002 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-long-case.html SHORT CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006002-short-case.html https://youtu.be/7jBj-Fz8kc4 3 1601006003 LONG CASE https://mbbs2k16batchgmpracticals.blogspot.com/2021/04/1601006003-long-case-50-
Read more

1601006161 SHORT CASE

Image
  SHORT CASE : A 34-YEAR-OLD GENTLEMAN WITH CHRONIC KIDNEY DISEASE UNDERGOING DIALYSIS   HALL TICKET NUMBER : 1601006161 A 34-year-old gentleman, from Motukur, who is a labourer by occupation, came to the hospital on 17/04/2021, for Maintenance Hemodialysis. History of presenting illness : The patient was apparently asymptomatic 3 years ago, when he was diagnosed with  Hypertension, secondary to Chronic Kidney Disease.  He was regularly taking his medication for Hypertension, until he  abruptly stopped  doing so 2 months ago. The patient has been  undergoing maintenance hemodialysis at our hospital since the past 10 months . He complains of facial puffiness, abdominal distension and swelling in the legs.  The patient also complains of loss of weight over the past 3 years. Initially, he was 63 kg, now he is 52 kg. General Physical Examination : The patient is conscious, coherent and cooperative, lying supine on the bed He is well oriented to time, place and person. He is moderately buil
Read more

1601006168 SHORT CASE

Image
  MEDICINE SHORT CASE This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.  Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.  This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome." I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.  CASE PRESENTATION: 34 year old male patient who is a labourer by occupation hailing from nalgonda came  to the OPD with a chief complaint of  Chest pain
Read more