1601006147 SHORT CASE

 GENERAL MEDICINE FINAL PRACTICAL CASE:

1601006147

"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. 



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 clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan


CASE


A 56yr old male , sales manager by occupation , resident of miryalaguda ,came to the opd with cheif complaints of easy fatiguability on exertion since 30 days


HISTORY OF PRESENTING ILLNESS


Patient was apparently asymptomatic 30 days back then he developed fatigue on excertion which was insidious in onset , gradually progressed to the present stage. ( He was able to walk 500m initially.... But now he can only walk 100m ) which was associated with Dyspnea on excertion , palpitations and body pains.


No complaints of - chest pain , cough , fever , hematuria .no malena


PAST HISTORY


No H/o DM , HTN, Asthma, Epilepsy, CAD


Family History


No significant history


PERSONAL HISTORY


Diet - Mixed

Appetite - Normal

Sleep - Adequate

B&B - regular

No Addictions


GENERAL EXAMINATION


Patient was conscious coherent and cooperative 


Moderatly built and nourished


Vitals 


Pulse - 94 bpm

Regular

Normal volume 

BP - 100/70 mm hg

Respiratory rate - 29 cpm 


Other Signs


Pallor - Present


Icterus - absent 


Cynosis - absent 


Clubbing - absent 


Koilonychia - Absent


Lymphadenopathy - absent 


Edema - absent 



SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM


S1 S2 Heard 

No murmurs

Apex beat heard at left 5th ICS


RESPIRATORY SYSTEM


Normal Vesicular Breath Sounds


CNS


All nerves are intact



GIT


No hepatospleenomegaly

Bowel sounds heard


Differential Diagnosis


Nutritional Anemia

Iron deficiency anemia


Provisional Diagnosis


Iron deficiency Anemia



INVESTIGATIONS


-Complete Blood picture

-Stool Examination ( occult blood )

-Urine Examination





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