Final Practical Short case

 

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's 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.  



A 60 year old male patient driver by occupation came to causality with chief complaints of Pedal edema since 20 days  , vomitings since 1 week , fever since 10 days , Shortness of breath since 7 days , decreased urine output since 5 days .

History of Present Illness 

 Patient was apparently asymptomatic 15 days back then he developed pedal edema in his lower limb which is pitting type fever which is continuous associated with cough and vomiting  since 5days.vomiting of one episode which is non projectile. Cough with sputum which  is red in colour and reduced after medication.

-SOB of grade 4 since 5 days

- After  completion  of (6) session of dialysis he has gone through acute ischaemic stroke.

Past history : 

He had a H/o giddiness 15 years back for which he went to hospital and diagnosed with diabetes and he discontinued medication since 6 years.

-He had H/o TB 15 years back

-Diagnosed wit hypertension since 2 years.

Personal history: 

Diet -mixed

Sleep - adequate

Appetite- Normal

Alcoholic since 30 years.

Family history: 

No similar history in the family 

General examination: 

Patient was conscious, coherent, not well cooperative

Pallor present 

-No cyanosis, clubbing, lymphadenopathy.

- pedal oedema which is pitting type.



Vitals;

Temperature -99.6 F

-B.P-140/80mm Hg

PR-85bpm

RR-26cpm

GRBS -237mg

Systemic Examination:

CVS S1S2+

RS -BAE +

Per abdomen - soft, nontender

CNS -No abnormalities detected

Investigations : 

Complete blood picture : 

Hb- 7.1gn/dl

TLC- 12,500

Lymphocytes -13

PCV -21.6

MCH- 22.7

RBC count- 3.13 million /cumm

RFT : 

Urea-132 mg /dl

Creatinine -10.1 mg/dl

Phosphorus -6.6 mg /dl

LFT :

Total bilirubin -0.76

ALP - 141

Total protein -5.8 gm/dl

Albumin -2.7 gm/dl


Diagnosis : 

Diabetic Nephropathy 

Treatment : 

Salt restriction-<2.4 gm/day

Fluid restriction <1 lit/day

Tab lasix 40 mg

Tab SHELCAL 500 mg.





Comments

Post a Comment

Popular posts from this blog

General medicine case 7

Image
  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. A 55 year old male who cuts the stone by occupatiom came to causality with chief complaints of pedal edema, facial puffiness and shortness of breath since 2 months and cough since 3 months.   History of present illness:  Patient was apparently asymptomatic 5 to 6 months back then he had traumatic eye injury ( right eye ) ,while he was cutting granite stone due to which he had lost his vision .  3 months back he developed cough occasionally which is wet type of cough . 2 months back he developed pedal edema which is non pitting type .he developed shortness of breath suddenly while doing work ,aggravated by doing work ,n
Read more

Prefinal examination

Image
Prefinal Examination :  1. Define heart failure , etiology, and clinical features of heart failure ? How do we diagnose heart failure clinically physical examination and various modalities used in daignosis of heart failure  . Write a brief note of tretament of heart failure  Ans :  2. Define cirrhosis of liver . Etiopathogenesis of cirrhosis. Write a brief note on clinical features,diagnosis and treatment of cirrhosis of liver .  3. Elaborate on clinical features and diagnostic modalities in diagnosis of Renal calculi  4. Etiology of pleural effusion . Diagnostic criteria of pleural effusion  5. Diagnosis and treatment of dengue fever  6. Clinical features and diagnosis peptic ulcer disease . 8.  Treatment of Abdominal tuberculosis  9. Etiology and treatment of Pneumonia  10. Complications of dialysis  11. Asicitic fluid analysis  13 . Afterload reducing agents in heart failure  14. Treatment of Urinary tract infection  15. Differential diagnosis of Fever with Rash  16. Insulin therap
Read more

General medicine Case

Image
  This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input. A 32 old male , mason presented to the opd with chief complaint of fever, cold , cough , headache and giddiness  since 1 week  History of present illness : Patient was diagnosed with dengue fever 1 week back where he had complained of low grade , intermittent fever with no diurnal variation associated with non productive cough and cold also complained of difguse headache with photophobia or phonophobia , giddiness especially on getting up from bed 1 week  Past history: Not a known case of diabetes , hypertension , epilepsy, Asthma, tuberculosis  No similar histor in the past  He was biten by dog in his childhood of whi
Read more