General Medicine- Short Case

 Hall ticket no. 1601006126

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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based input.

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

Case- 

A 55 years old man, resident of Nalgonda farmer by occupation came to the OP with chief complaints of- 

-Swelling in both the legs 

-Reduced urine output 

History of Presenting Illness- 

Patient was apparently asymptomatic 10 days ago then he noticed bilateral pedal edema developed gradually and decreased urine output.

No h/o fever, burning micturition, hematuria

No h/o of chest pain, cough, expectoration , hemoptysis, reccurent respiratory tract infections.

 No h/o palpitations, syncope.

No history suggestive of hypo or hyperthyroidism.

Past medical History- he is a known case of Hypertension 

He is not a known case of diabetes mellitus, bronchial asthma, thyroid disorders, epilepsy, coronary artery disease. 

Personal history :   

-consumes mixed diet 

- appetite is reduced

-sleep- adequate

-Bowel movements regular

-bladder habits irregular 

Consumes alcohol occasionally

-No habit of smoking and tobacco and Pan chewing 

Family history:- 

No significant family History

Treatment history:- he is on antihypertensive medication. 

General Examination- 

Patient is conscious, coherent and cooperative. 

He is moderately built and nourished. 

He has no signs of pallor, icterus, clubbing, koilonychia, b/l pedal edema is present. 

Pulse rate- 98bpm

Respiratory rate- 18/min

Blood pressure- left arm- 130/90mm hg 

Cardiovascular examination- 

S1 and S2 heard. 

No thrills and murmurs 

Respiratory system examination- 

Bilateral air entry presents, vesicular breath sounds + 

No dyspnea, wheezing

Position of trachea- Central 

ABDOMEN

Shape of abdomen - Scaphoid

No Tenderness 

No Palpable mass

Hernial Orifices - Normal

No Free Fluid 

No Bruits 

Liver Not palpable  

Spleen - Not palpable

Investigations:- 

Ultrasonography finding- Renal parenchymal disease of grade- 2.

Provisional Diagnosis: Chronic Kidney Disease etiology- secondary to systemic Hypertension. 

Management:- 

Tablet- Laxix 40mg 

Tablet- Nicardia 20mg 

Tablet- Met xl 

Tablet- Nodosis 

Tablet-  Arkamine 

Tablet- human atropine. 

With respect to renal failure, compensated by regular hemodialysis. 

General Medicine Final Exam- Long Case-

Hall ticket no. 1601006126

This is an online e logbook to discuss our patients deidentified health data shared after taking her/guardian's signed informed consent

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs

This E log also reflects my patient centre’s online learning portfolio and valuable inputs on the comment box is welcome.

Case Presentation of Upper motor neuron lesion who is also a known case of diabetes and hypertension.

A 50 years old female, from Suryapet who is a homemaker was brought to the OP as she was unable to lift her left arm and left leg. and her mouth was deviated to right side since 3 days.

History of Presenting Illness- 

The patient was apparently asymptomatic 7 days ago, then she felt dizzy for a brief period of time.

3 days ago, she felt weakness during morning hours in her left arm while making breakfast and noticed weakness in her left leg followed by fall on the floor. 

Weakness was sudden in onset and rapidly progressed to a state where she was unable to move her left side of the body. 

There were no similar attacks in the past.

There was no history of headache, nausea, vomiting, fever or burning micturition and she is not a known case of migraine.

No sensory impairment, no dysphagia, no giddiness, no tinnitus, no hearing impairment, no visual disturbance, no bowel and bladder incontinence and no new gait abnormality

Past medical history- 

She is a known case of diabetes mellitus since 5years and Hypertension since 3 years for which she was on medication.

Glimipramide 0.2mg 

Voglibose 0.2mg and 

tenegliptin 20mg 

Metformin 500mg 

Telmesartan 40mg 

Amlodipine 125mg. 

She is not a known case of Tuberculosis, bronchial asthma, thyroid disorders, epilepsy.

Menstrual history

She had undergone hysterectomy 4 years ago for fibroid uterus

Family history:- No significant history.

Personal history 

she has mixed diet

Normal appetite.

Bladder habits are regular.

bowel movements are irregular.

she has not been able to pass stools since 5 days. 

No allergic reactions to any known drugs

General Examination:- 

The patient was conscious cooperative oriented to the time place and person and cooperative lying on the bed in supine position. 

Patient was afebrile

Pulse = 69 beats per minute.

- Blood pressure = 140/70 mm of Hg.

- Respiratory rate = 16 cycles per minute.

- JVP is not elevated

- There is NO Pallor, Icterus, Clubbing, Cyanosis, Generalized lymphadenopathy and Edema.

Nervous system examination

the patient is conscious, alert, oriented and cooperative.

Higher mental function is intact and presence of slurring of speech. 

Right handedness

Cranium and spine- no abnormalities detected.

Signs of meningeal irritation- neck rigidity, Kernig's, Brudzinski are negative 

there is no kinking or bruits in carotid arteries.

Cranial nerves examination:- 

Pupils- left and right reactive to light 

3rd, 4th, 6th no abnormalities

5th nerve- sensory- normal 

                               - motor- jaw jerk +ve 

7th nerve- mouth deviation towards- right

  Drooling of contents of food from left side

 frowning present

-absent nasolabial folds on left side

-blowing and whistling absent

Taste sensation on anterior 2/3rd of tongue present

Corneal reflex present on both sides

Vestibulocochlear nerve- Rinnes Weber, Schwabach test normal on both sides

9th, 10th, 11th- gag reflex +

Motor function- 

Nutrition- normal- no wasting seen on both sides

Tone- right upper limb- normal

            Right lower limb- normal

            Left upper limb- normal 

            Left lower limb- normal

Power- right upper limb- 5/5

            Right lower limb- 5/5

            Left upper limb-  0/5

            Left lower limb- 0/5

Reflexes:-                       Right               left

  i) Superficial Reflexes 

. Corneal reflex          present         present

. Conjunctival reflex present       present

. Plantar reflex          flexor             extensor

   ii) Deep Reflexes

                       Right          left

Biceps              +2              +3

Triceps              +2          +3

Supinator         + 2           +3

Knee                 +2             +3              

Ankle.                Not elicited              

Plantar              flexor    Extensor

Sensory system  

Superficial -fine touch,temperature, pain -present

Deep-position, vibration, crude touch, stereognosis, 2point discrimination- present 

Cerebellum- Speech, nystagmus, tremors- absent

Coordination

Finger nose test ,finger finger test,heel knee test-present

    

Cardiovascular system- S1 and S2 heard no murmurs, not a known case of valvular heart disease atrial fibrillation

Respiratory system- Bilateral air entry present

Respiratory-Normal vesicular breath sounds,bilateral air entry present

GIT -no significant findings

Provisional Diagnosis-

Left Sided hemiparesis with left UMN type of facial paresis (due to right middle cerebral artery infarct)

Medical Management- 

Aspirin 75mg 

Clopidogrel 75mg 

Pantoprazole 40mg 

Atorvastatin 40 mg

Physiotherapy 

GRBS monitoring 8th hourly.