General Medicine Final Practicals Examination - LONG CASE
KP Pranay
Hall ticket no: 1701006095
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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.
LONG CASE
A 46 year old male came to hospital with the chief complaints of
-burning micturition since 10 days
-vomiting since 2 days (3-4 episodes)
-giddiness and deviation of mouth since 1 day
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus,he was started on OHAs, 3years back OHAs were converted to insulin.
20days back he developed vomiting containing food particles, non bilious,non foul smelling(3-4 episodes),later he complained of giddiness and deviation of mouth for which he was brought to our hospital and his GRBS was recorded high value for which he was given NPH 10U and HAI 10U.
No history of fever/cough/cold.
No significant history of UTI's.
Past history:
10years back- patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus he was started on oral hypoglycemic agents(OHA) 10years back
3years back- OHAs were converted into Insulin
3years back- he underwent cataract surgery
1year back- he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.
Delayed wound healing was present- it took 2months to heal
Not a k/c/o Hypertension, Epilepsy,Tuberculosis, Thyroid
Not on any medication
No history of blood transfusion
PERSONAL HISTORY:
Diet - Mixed
Appetite- normal
Sleep- Adequate
Bowel and bladder- Regular
Micturition- burning micturition present
Habits/Addiction: Alcohol- Not consuming alcohol since 1 yr.
Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.
FAMILY HISTORY:
Not significant
VITALS @ Admission:
BP: 110/80 mmHg
HR: 98 bpm
RR: 18 cpm
Temperature: 99°F
SpO2: 98% on RA
GRBS: 124 mg/dL
GENERAL EXAMINATION:
Pallor: present
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Lymphadenopathy: Absent
No dehydration
CVS: S1 and S2 heard, No murmurs
RS: BAE+, Normal vesicular breath sounds heard
P/A: Soft, Non tender
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:
On admission (19.5.22)
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