1601006103 SHORT CASE

 

1601006103 - SHORT CASE


A 56yr old male sales manager by occupation resident of Miryalaguda came to the hospital with the chief complaints of easy fatiguability on excertion 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 upto a distance of 100m ) which was associated with dyspnea on excertion , palpitations and body pains.
No complaints of - chest pain , cough , fever , hematuria .


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 hepatosplenomegaly
Bowel sounds heard


DIFFERENTIAL DIAGNOSIS:
Nutritional Anemia
Iron deficiency anemia


PROVISIONAL DIAGNOSIS:
Iron deficiency Anemia

INVESTIGATION:
-Complete Blood picture
-Stool Examination ( occult blood )
-Urine Examination




TREATMENT- 
 Diet Rich in Iron
 Ferrous Sulphate 200mg OD


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