Short Case - GENERAL MEDICINE FINAL PRACTICAL EXAMINATION

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient 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 comments in comment box are most welcomed 


Chief Compliant :

A 46 year old male came to opd with complaints of, 
Fever on and off episodes: since15 days
Loss of appetite:15 days
B/L lower limb swelling:10 days
Yellowish discoloration of eyes and nails :7 days


History of Present illness:

Patient was apparently asymptomatic 15 days back then he complained of fever which is low grade, intermittent, on and off episodes get relieved on medication. 

Patient complained of pedal edema present below the knees, pitting type, present since 10days which get aggravated on standing for long periods and slightly reduced on taking rest. 

Shortness of breath present since 10 days.
Patient also complained of loss of appetite :15 days

Patient also complained of abdominal tightness, bloating of abdomen(gastric trouble)

No History of chest pain,vomitings, constipation, loose stools. 
No History of burning micturition, decresaed urine output. 
No Headache, Confusion. 


PAST HISTORY:

Patient Is Known Hypertension since 3 years and on medication. 

Not a K/C/O DM, Asthma, TB, Epilepsy, CAD, CVD. 


PERSONAL HISTORY:

Appetite:Normal(Decreased since 15days) 

Diet:Mixed

Bowel and Bladder habits:Regular

Addictions:
Consumes Alcohol since 25 years regularly (daily Quarter (90ml) 

Tobacco chewing since 5 years (Gutka,Zhardha)


GENERAL EXAMINATION:

Patient is Conscious, Coherent, Co-operative and we'll oriented to place person and time

Pallor-Present
Icterus-Present
Cyanosis-Absent
Clubbing-Absent
Lymphadenopathy:Absent
Pedal edema- B/L Pedal edema present upto knees


ON ORAL EXAMINATION :

Halitosis (Bad breathe)

Patient is having Severe ATTRITION of tooth

Suspected "Tobbaco pouch keratosis on Buccal Mucosa"

Patient undergone RESTORATION on Maxillary 2rd molar

Tobbaco Stains +++

Calculus ++

Opinion - "Poor oral hygiene"



CLINICAL IMAGES:









Vitals:

TEMPERATURE: Afebrile
PULSE RATE: 90 beats /min
RESPIRATORY RATE:19Cycles/min
BP:100/70mm of hg 


SYSTEMIC EXAMINATION:

Respiratory System : Bilateral air entry present.
vesicular breath sounds heard.
Position of trachea -central.

Central Nervous System : patient is conscious coherent and cooperative.
Sensory System - Normal
Motor system -Normal

Cardiovascular System: 
S1S2 sounds are Heard 


Abdomen:
Abdomen:
-Shape of abdomen: Scaphoid 
-Tenderness: No
-Umbilicus: inverted 
-Dilated veins: No
-Liver : palpable
-Spleen: not palpable
- Bowel sounds: Heard


INVESTIGATIONS:


USG ABDOMEN 

Ascitic fluid examination :
"SAAG:1.5"

Liver Function Test (LFT) :

Total bilirubin - 21.01mg/dl
Direct bilirubin - 16.75mg/dl
AST (aspartate transaminase) -63
ALP (alkaline phosphate) - 188
ALB (albumin) - 2.5

=="FEVER CHART"==
TLC on date 11/01/2023   :   43,000
TLC on yesterday 18/01/2023   :  32,660
There is progressive decrease in TLC count.


DIAGNOSIS:
- Chronic liver disease with
Moderate Anemia,(Vitamin B1 deficiency)


TREATMENT:
-Inj Monocef 1gm IV/BD

-Syrup Lactulose 30ml 
-Inj Lasix 20mg IV/BD
-Inj Thiamine 100mg 



Comments

Post a Comment

Popular posts from this blog

A 19 year old male with fever and severe body pain

Sir this case was taken on 23rd September A 19yr old male patient came to the opd with chief complaints of fever Since 1 week. HOPI:- Patient was Apparently asymptomatic 1 week back then he developed fever with chills which is high grade ,sudden in onset & associated with body pains .Relieved on medication. 2 days back he was taken to outside hospital there his platelet count was 1,29,000 cells/cumm, yesterday they were 1,32,000cells/cumm.Today they were 98,000cells/ cumm. No h/o Loose stools, vomitings, No h/o Hematuria, dark stools. No h/o pain abdomen,giddiness. PAST HISTORY:- Not a k/c/o HTN,DM, Thyroid, Epilepsy. PERSONAL HISTORY:- diet- mixed Appetite- normal Sleep- adequate Bowel and bladder movement- normal GENERAL EXAMINATION:- Patient was conscious, coherent, cooperative,well oriented to time place and person. Moderately built & moderately nourished. No pallor,Icterus,cyanosis, lymphadenopathy, clubbing. BP -90/60mmhg PR -84 RR -14cpm Spo2 -99 Temp:-99.5 F CVS- S1 S2
Read more

LONG CASE - GENERAL MEDICINE FINAL PRACTICAL EXAMINATION

Image
This is a 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 patients problems through series of inputs from available global community of experts with an aim to solve those patients 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 in comment box is welcome. CHIEF COMPLAINTS: 38 year old female Came to OPD with an Chief complient of : Poor stream of urine since 1 month.  Dysuria (painful urination) since 18 days  Burning micturition since 13 days  Pain in lower abdomen since 13 days History of Present illness  : Patient was apparently asymptomatic 1 month back , then she developed poor stream of urine  she developed pain during micturition since 18 days.  Pain in lower abdomen Spasmodic type of pain non radiating  with no aggrevating and relieving fac
Read more