1601006060 LONG CASE

 

HALL TICKET NO: 1601006060. LONG 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

HALL TICKET :1601006060.


A 45 year old male resident of Nalgonda labourer by occupation presented to our opd on 20 april  with chief complaint of : 
         .      Pedal edema since 15 days 
         .      Oliguria since 15 days
         .     Burning  micturition since 10 days
         .      Fever since 10 days
• shortness of breath since 8 days  
• Cough since 8 days 
   

History of presenting illness :-

 Patient was apparently asymptomatic 15 days ago,then developed —
 
• Bilateral pedal edema,     since 15 days which in insidious in onset , gradually progressed up to the thighs, pitting type , no aggravating and no relieving factors 

. Decreased urine output  since 15 days.
 
. There is history of fever since 10 days which is insidious in onset , intermittent , not associated with chills and rigors , headache , vomiting .

.History of burning micturition and oliguria since 10 days 

 . Shortness of breath since 8 days   which was insidious in onset, non progressive, aggrevating by walking and sternous work and relieved by taking rest.
( Grade lll ).
He has history of orthopnea.
There no history of PND.

.Dry cough :-
He has dry cough since  8 days, which is insidious in onset, non progressive, no aggrevating and relieving factors.

  . His appetite has decreased.

• There is no history of sweating , palpitations , chestpain , hematuria 
  *  patient underwent 2 sessions of  Dialysis  after admitting in our hospital.
 
Past history 
•    2 years back he developed symptoms of  productive cough and fever for 1 week for which he visited to hospital and diagnosed with Tuberculosis and took  antitubercular drugs for 6 months and at that time he was told be having some kidney issues and used some medications ( records notavailable ) .

 
• Not a known case of diabetes ,hypertension,asthma , convulsions

• Surgical history is not significant.      

Family history 
          Not significant 

Personal history 

•  decreased appetite 
• Mixed diet
• Regular bowel habits and normal 
• Patient has oliguria and burning micturition 
• He is an alcoholic since 10 years  ,drinks once   weekly 
• Smoker since 25 years , he smokes daily 2-5 beedis 

 GENERAL EXAMINATION 

   Patient is conscious coherent and cooperative  , moderately built , moderately nourished 
⁃ Presence of pallor 
⁃ No icterus , no cyanosis, no clubbing,no pedal edema 
⁃ No generalized lymphadenopathy  






 Vitals 
⁃ Pulse taken  in sitting position ,left                        radial pulse ,Pulse rate : 80bpm ,                            regularly regular 
⁃ Bp 130/80 mm hg measured in sitting                 position on right upper arm 
⁃ Respiratory rate : 20cpm
⁃ Afebrile 
 
RESPIRATORY SYSTEM EXAMINATION 
 
 Patient is examined in supine aswell as in sitting positions under well ventilated room with consent taken 

 Upper respiratory tract :
     nose , oral cavity  are examined and no abnormal findings are present 

 examination of chest proper :
  • Inspection 
⁃ shape of chest : normal 
⁃ Symmetry of chest : symmetrical 
⁃ Trial sign negative 
⁃ Movements of chest : RR -20cpm                  .   .                
                         Type - abdomino thoracic.                        
  .                      Equal on both sides 
⁃ No involvement of accessory muscles                 and no intercoastal tenderness 
⁃ No visible scars , no sinuses , no                            engorged veins 
⁃ No deformities of spine 
⁃  No visible apical impulse 



  • palpation 
⁃ No tenderness and no local rise of                        temperature 
⁃ Inspectory findings are confirmed
⁃ Trachea central 
⁃ Apex beat : felt at 5 th Intercoastal                        space lateral to mid clavicular line
⁃ Decreased  chest expansion 
⁃ Vocal fremitus : decreased  at infra                       axillary and infra scapular areas on                       both sides   normal on supra clavicular,               infraclavicular ,mammary , infra                             mammary , suprascapular and                                interscapular areas 
  •   Percussion 
  1. Direct percussion: resonant on clavicle , sternum 
    2.   Indirect percussion : 
  Anterior :
⁃   resonant in supra clavicular area 
⁃ Resonant in infraclavicular  area 
⁃ Resonant  in inframammary area on both sides 
⁃ Traube’s space:dull  
  Posterior :
⁃ Resonant in suprascapular area 
⁃ Resonant in interscapular area 
⁃ Dull in Infrascapular area on both sides 

  • Auscultation   
⁃ Bilateral air entry present 
⁃ Normal vesicular breath sounds heard 
⁃ Reduced in  B/ L infrascapular  and                        infra axillary areas 
            - fine crepts heard on B/L infra axillary                    and infra scapular areas 
 
CVS EXAMINATION 
 
⁃   S1 s2 heard 
⁃ No murmurs 
⁃ No palpable  thrills 

ABDOMINAL EXAMINATION 

 Scaphoid shape 
No tenderness 
No palpable mass 
No hepatosplenomagaly 
No ascites 
Bowel sounds  present 

CNS EXAMINATION 

⁃  Conscious and alert 
⁃ Normal gait 
⁃ Normal speech 
⁃ No signs of meningeal irritation 
⁃ Cranial nerves , motor system ,                              sensory , glasgowcoma scale normal 
⁃ Reflexes : superficial and deep tendon                  reflexes are intact 
 
Provisional diagnosis :
ACUTE ON CHRONIC RENAL FAILURE with past history of pulmonary TUBERCULOSIS . 
 
INVESTIGATIONS 

⁃ CBP
⁃ CUE
⁃ ABG
⁃ RFT 
⁃ LFT
⁃ PT
⁃ APTT
⁃ Blood sugar 
⁃ ESR 
⁃ Serum pottasium 
⁃ Blood culture 
⁃ Chest x ray 
⁃ ECG 
⁃ Ultrasound abdomen 



    






TREATMENT 

⁃ Salt and fluid restriction 
        Salt - < 2 g/ day 
        Fluid - < 1 lt / day 
⁃ Injection  iv LASIX 40mg BD 
⁃ Tab NODOSIS  500mg bd 
⁃ Tab SHELCAL 500mg od
⁃ Input and output charting 
⁃ Nebulization with mucomist and                            BUDICORT 12 th hrly 
⁃ Bp  pulse  spo2 charting 

 







Comment

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.blogsp...
Read more

1601006172 LONG CASE

Image
  50 year old with Weakness of left half of the body I have 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 diagnosis with a treatment plan.    This is an online E log book to discuss our patient’s de-identified health data shared after taking her guardian’s signed informed consent. Hall ticket number: 1601006172  Date of admission: 20/4/2021 Date of examination of patient: 24/4/2021 A 50 year old right handed lady, who is a farmer by occupation, hailing from Vardhamanapeta came with  Chief Complaints:   Weakness of left upper limb and lower limb since 5 days.  Slurring of speech since 5 days.  Deviation of angle of mouth to right since 5 days.  History of Presenting illness:  She was apparently asymptomatic 5 days back.  On 20th of April, She woke up and...
Read more

1601006184 LONG CASE

Image
  1601006184 LONG CASE : A 50 year old female hailing from cherkupalli, housewife by occupation came to the OPD with  chief complaints of pain and stiffness in several joints since 3 months.  HISTORY OF PRESENTING ILLNESS : She was apparently asymptomatic 9 years ago, then she developed a dull aching type of pain and stiffness in her finger joints(metacarpophalyngeal joints) of right hand.  After 5 months of onset, the pain and stiffness progressed to invovle other joints( wrist joint and elbow joint) of both hands. Within 5 years of onset she started feeling pain in the joints of the feet and ankle.  Pain  was insidious in onset, slowly progressive, dull aching type, non radiating type,associated with swelling and limitation of movements of the involved joints. Pain and stiffness were aggravated by rest and relieved on activity. Since 3 months the pain was unbearable & was limiting her activities. Stiffness and pain was more in the morning for 1 hour a...
Read more