Final practical Examination-Long Case

 A 25 year old Male presented to OPD with chief

 complaints of  vomitings 10 episodes and

 bipedal edema and decreased urine output 

since 3 years.


HISTORY OF PRESENT ILLNESSES:

Patient was apparently asymptomatic 3 years ago


 then  he developed multiple episodes of vomitings 


for which he was admitted in the hospital and found 


to have high BP of 170 mm Hg



HISTORY OF PAST ILLNESS:


Known history of hypertension .


Known history of Tuberculosis No history of 


Diabetes mellitus asthma, epilepsy.


No history of surgeries, chemotherapy or 


radiotherapy 


PERSONAL HISTORY:


 Diet - Mixed 

 

Appetite- Normal 


Bowel movement is regular .


Micturition - Normal 


Addictions- None 


Sleep  - Regular 


FAMILY HISTORY :


No history of DM, CAD, Asthma and thyroid 


disorders in the familyGENRAL EXAMINATION 


Patient is conscious, coherent, co-operative.


There are no signs of icterus, clubbing, pallor, cynosis, lymphadenopathy


VITALS


Temperature- 98.4  


Pulse rate-  78 bpm


Respiratory rate - 13cpm 


BP- 130/80 mm Hg


Spo2-  98%


GRBS -112mg/dl




SYSTEMIC EXAMINATION:


Cardiovascular System


Cardiac sounds- S1, S2  are heard

No cardiac murmurs


RESPIRATORY SYSTEM


Position of trachea- central


Breath sounds- vesicular


Adventitious sounds- No


 

ABDOMEN


Shape of abdomen - Scaphoid 


No tenderness . 


Hernial orifices -Normal


Palpable mass- None 


Free fluid- none 


Liver- Not palpable


Spleen- Not palpable


Bowel sound- Heard




CENTRAL NERVOUS SYSTEM 


Patient is conscious 


Speech- normal


No sign of meningitis 


Motor and sensory system- Normal


Neck stiffness - none 


Kernings sign - none 


Cranial nerves- intact


Investigation 


 

Hemogram : Hb - 7.5 gm/dl

 

Total cell count -9700 cells / cubic mm


Neutrophils-71 % 


MCV -91.7  


MCHC - 33.8 


Serum electrolyte 


Creatinine - 5.4


Na +  146 mEq/L


K+ 3.9 mEq/L


Cl 98 mEq/












Provisinal Diagnosis: Chronic Kidney disease 


TREATMENT


Conservative- Maintaince Heamodialysis 


On 05 -02-22


Fluid  restriction  < 1L / day 

Salt restriction < 2.4 g / day 

Tab. Nicardia 10 mg BD 

Tab . Lasix 40 mg BD 

Tab . Shelac  OD 

Tab . Pan 40 mg OD 

Tab . Ororex  XT OD

Tab . Nodosis. 550 mg OD 


  On 9-2-22


Tab. Nicardia 10 mg BD 

Tab . Lasix 40 mg BD 

Tab . Shelac  OD 

Tab . Pan 40 mg OD 

Tab . Ororex  XT OD

Tab . Nodosis. 550 mg OD 


Comments

Post a Comment

Popular posts from this blog

Case of Acute Bronchiectasis

Image
A 42 year old female patient came to casuality on   15/12/21 with chief complaints of Shortness of breath  since 3 months, fever since 7 days,cough since 10  days and decreased urine output since 2 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 3 months back  after which she developed SOB which was insidious in  onset with orthopnea. Patient developed cough since 10 days with  expectoration (mucoid, minimal, foul smelling and not  blood stained) increased on lying down and decreased  when sitting down. Patient complaints of  fever since 7 days with chills. Decreased urine output since 2 days . Patient had history of tuberculosis 6 years back for  which she was on medication for 8 months and cured completely . Patient is not known case of diabetes mellitus ,hypertension and ischemic heart disease.    - h/o similar complaints for the past 6 months(became severe since 10 days . Patient is labor worker  by occupation and she may be exposed to biomass and dust since 2
Read more

Case of Chronic Kidney Disease

Image
This is an online elog to discuss patient deidentified health data shared after taking his /her guardian signed informed consent.Here we discuss about our individual patient's problem through series of inputs from available global online community of experts with an aim to solve the patient's clinical problem with collective current best evidence based input .  This eblog also reflects my patient's centered online learning portfolio and your valuable inputs in the comment box is welcome. Date of admission : 04/08/2021 A 55 year old man,mechanic by occupation presented to the OPD with chief complaints of decreased urine output since 1 day. HISTORY OF PRESENT ILLNESS :  Patient was apparently asymptomatic from past one year.On date 20/7/2021 patient had sudden onset of shortness of breath so taken to hospital,treated with oxygen supply. Doctors told him that he has elevated creatinine levels in blood and advised to undergo dialysis. On 26/7/21 patient is being prepared for  c
Read more

General Medicine Prefinal Assessment

Image
 1.Define Heart failure. Ethiology and Clinical features of Heart failure . How do we diagnose heart failure clinically ,physical examination and various modalities used in heart failure . Write a brief note on treatment of heart failure.  2. Define Cirrhosis of liver.Ethiopathogenesis of cirrhosis. Write a brief note on clinical features,diagnosis and treatment of cirrhosis of liver. 3. Elaborate clinical features and diagnostic modalities in diagnosis of Renal calculi 4.Ethiology of Pleural effusion .Diagnostic criteria of Pleural effusion.  5. Diagnosis and treatment of Dengue fever. 6.Clinical features and diagnosis of Peptic Ulcer disease.  7.Treatment of Acute pyelonephritis. 8. Treatment of Abdominal tuberculosis 9.Ethiology and Treatment of Pneumonia  10. Complications of Dialysis  17.Antihypertensive drugs in Chronic renal failure 20. Hormones secreted by Pituitary gland 16.Insulin therapy in diabetic mellitus  15. Differential diagnosis of "Fever with Rash" 14. Trea
Read more