1601006079 LONG CASE

 

1601006079



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, vomiting and loose stools since 6 days.


*HISTORY OF PRESENT ILLNESS-


The patient was apparently  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 - normal 

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-



   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.blogsp...
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, ...
Read more

1601006107 LONG CASE

Image
  LONG CASE : A 50-YEAR-OLD LADY WITH LEFT-SIDED WEAKNESS OF THE BODY AND DEVIATION OF THE MOUTH TOWARDS THE RIGHT A 50-year-old lady, from Suryapet, who is a homemaker, came to the hospital on 20/04/2021 at 3 PM, and was examined on 24/04/2021 at 10 AM, with Chief Complaint s  of : 1) W eakness of the left upper and lower limbs since 5 days 2) Deviation of the angle of mouth towards the right since 5 days 3) Slurred speech since 5 days. History of Presenting illness  :  The patient was apparently asymptomatic  5 days ago , when  at around 9 AM in the morning, on 20/04/2021 : She felt a sudden  weakness of her left upper and lower limbs. The episode was  sudden in onset, initially began as a slight weakness of the left upper limb, which progressively worsened with time and the evolution of weakness had completed within 6 hours ,  with a complete inability to move both - her left upper and lower limbs ,   following which she was brought t...
Read more