Short Case - GENERAL MEDICINE FINAL PRACTICAL EXAMINATION

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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 



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