1601006180 SHORT CASE

 

1601006180



A 45 year old male resident of Nalgonda labourer by occupation presented  with chief complaint of : 
• shortness of breath since 10 days  
• Cough since 8 days 
• swelling of legs since 8 days 


History of presenting illness  

Patient was apparently asymptomatic 10 days ago,then developed —
• Grade III  shortness of breath which was insidious in onset , nonprogressive,aggravated by walking  and strenous work  and dressing , relieved by sitting             
               There is history of orthopnea                        
               There is no history of PND 
• Dry Cough  since 8days which is insidious in onset , non progressive ,no aggrevating and relieving factors 
•  Grade III bilateral Pedal edema  since 8 days which in insidious in onset , gradually progressive,pitting type , no aggravating and no relieving factors 
        .      fever since 8 days which is insidious in onset ,with evening rise of temperature , intermittent , not associated with chills and rigors , headache , vomiting 
• History of burning micturition and oliguria since 5 days 
• There is no history of sweating , palpitations , chestpain , hematuria 

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  medial 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 
⁃ Reflexes : superficial and deep tendon reflexes are intact 

INVESTIGATIONS 




    




 

Provisional diagnosis :ACUTE ON CHRONIC  RENAL Failure with bilateral Pleural Effusion
past history of  pulmonary TUBERCULOSIS 

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 
⁃ Bp  pulse  spo2 charting 


 










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

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 to the hospital by her family members, at around 
Read more