General Medicine Final Practical Examination - Short Case
KP Pranay
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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
SHORT CASE:
A 80 years old male resident of Marrigudem, agriculture labourer by occupation came to OPD with the chief complaints of
-Fever since 3 days
-An episode of vomiting 2 days back
-Decreased urine output associated with burning micturition since - since 2 days
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 3 days back.
He has fever which was insidious in onset,gradually progressive, with no diurnal variations and relieved on medication. It was associated with chills, rigors and generalised body pains. It is not associated with cough, cold, shortness of breath and night sweats.
An episode of vomiting 2 days back which is of only food which is non bilious and not foul smelling and colour is same as the food colour.
There is burning micturition which is experienced at the start of the urinary flow and relieved after the urination and decreased urine output since 2 days which is not associated with any hematuria.
PAST HISTORY:
He was with similar complaints in the past 10years ago, then he consulted a local doctor and relieved on medication (may be antibiotics). And there is continuation of such episodes then refered to higher hospital and diagnosed with renal problem (AKI) which was treated with dialysis once and given some diuretics as he is suffering from oliguria.
He has a recurrent episodes of fever with burning micturition later also.
He is known case of hypertension since 24years.
Not a known case of Diabetes, Tuberculosis, Asthma and Epilepsy.
SURGICAL HISTORY:
He had underwent a nephrectomy surgery 27 years ago. Donated a kidney to his brother.
PERSONAL HISTORY:
Appetite - normal
Diet- mixed
Sleep - adequate
Bowel - regular
Bladder - oliguria since 2 days, associated with burning micturition, feeling of incomplete voiding.
Habits/Addiction: 3 beedi/ day from 27yrs of age and Alcohol- occasionally.
He stopped both alcohol and smoking after the nephrectomy surgery.
GENERAL EXAMINATION:
Patient is conscious, coherent, co operative and well oriented to time, place, and person moderately build and nourished.
Pallor: Present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
Pedal edema: Present
It was gradually progressive, pitting type, bilateral, Below knees.Grade 2
No local rise of temperature and tenderness
Not relived on rest.
Pallor
Pedal edema
VITALS:
Febrile 99.2F
BP : 150/90 mmHg (on medication)
Pulse rate: 76 bpm
SYSTEMIC EXAMINATION:
CVS: No visible pulsations, scars, engorged veins. No rise in jvp. Apex beat is felt at 5 ics medial to mid clavicular line. S1S2 heard . No murmurs.
RS: Shape of chest is elliptical, b/l symmetrical. BAE+, Normal vesicular breath sounds heard.
Per abdomen:
No visible pulsations and scars swellings.
Soft, non tender, no organomegaly.
Umbilicus is inverted.
No abdominal distention
CNS:
Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar) Normal
Power: Normal(5/5) in both Upper and Lower limbs
Tone: Normal in both Upper and Lower limbs
No meningeal signs.
INVESTIGATIONS:
TREATMENT:
Inj. Piptaz -2.25gm/tid
Tab. Lasix - 40ug/po/ bd
Tab. Zofer - 4mg/po/ sos
Tab. Dolo - 650/ po/ sos
Tab. Pan 40mg /po/ od
Nebi. Duolin and Budecort 6hrly
Syr. Mucaine gel 15ml/po/ bd before meal 15min
Syrup. Cremaffin 15ml/po/ sos.
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