GENERAL MEDICINE


A 60 year old man , Shop keeper by occupation , resident of Khammam came with the 

CHIEF COMPLAINTS - 

 • Fever since 3 months 
• Loss of appetite since 3 months 
• cough since 3 months 
• Shortness of breath since 2 months 
• Decreased urine output since 15 days 

HISTORY OF PRESENT ILLNESS - 

• Patient was apperantly assymptomatic 15 days , then he developed fever which is continuous on and off and subsiding on medication .
• Loss of appetite since 3 months 
• cough since 3 months Dry cough on and off and subsided by medication .
• Shortness of breath Grade 2 on exertion 
• Decreased urine output since 15 days 

HISTORY OF PAST ILLNESS 

IN 2016

• Patient was diagnosed with Dengue admitted in a private hospital where he was treated symptomatically & other investigations showed increased levels of Creatinine and uric acid .
• Patient had severe joint pains  ( PIP & DIP )  and swelling due to accumulation of Uric acid and on medication (? Unknown ).

IN JUNE 2022

• Patient had severe itching all over body , Fever , joint pains , for which he was taken to Hospital where
Investigations showed - 
Creatinine - 6.2 mg/dl 
Blood urea - 145  mg/dl 
Uric acid - 9 mg/dl 
and he was diagnosed with CKD .
2 sessions of Hemodialysis was done .

IN DECEMBER 2022

• Patient had complaints of Fever which is continuous and subsiding on medication  and Shortness of breath (Grade III ) for which he was brought to our hospital 

• He is a k/c/o Hypertension since 7 years and on medication ( T.Metoprolol 25mg OD )
• Not k/c/o DM 
• No H/o Bronchial asthma
• No H/o CVA , CAD 
• No H/o Epilepsy

PERSONAL HISTORY

Diet - Mixed 
Appetite - Decreased
Sleep - Inadequate 
Bladder - Decreased urine output 
Bowel movements - Regular 
Alcoholic occasionally 

FAMILY HISTORY

• Not significant

SURGICAL HISTORY 

Cataract surgery to left eye 6 months ago 

GENERAL EXAMINATION

Patient is concious , coherent , co-operative 
Well oriented to Time place person 
Thin build and moderately nourished 
• Pallor - Present 
• Icterus - Present 
• Clubbing - Absent 
• Koilonychia - Absent 
• Lymphedenopathy - Absent 
• Pedal oedema + Grade 1 Pitting type ( upto ankle)
• JVP - Normal 

VITALS

• Temperature - 102°F 
• Pulse rate - 110 bpm
• Respiratory rate - 24 cpm
• BP -  130/90 mmHg
• SPO2 - 98% on room air 
• GRBS - 157 mg/dl 

CLINICAL IMAGES 



SYSTEMIC EXAMINATION 

RESPIRATORY SYSTEM 

INSPECTION 

• Chest is elliptical , bilaterally symmetrical shape.
• Trachea is in central 
• Movements are bilaterally  equal 
• JVP - Normal 
• No visible scars and sinuses .

PALPATION 

• All the inspectory findings are confirmed , 
• Trachea is in centre 
• Movements  are bilaterally equal
• Apex beat felt in Left 5 th ICS , 1 cm lateral to the midclavicular line 
• Vocal fremitus decreased

PURCUSSION 

• Dull note heard in all areas of lung 

AUSCULTATION 

• Decreased air entry bilaterally +
• Normal vesicular breath sounds + 
• Breath sounds decreased bilaterally.


CARDIOVASCULAR SYSTEM 

INSPECTION 

• Chest is Elliptical and bilaterally Symmetrical
• Trachea - Centre 
• JVP - Normal 
• Transverse diameter > Anterio posterior diameter.
• No scars and sinuses 

PALPATION 

• All the inspectory findings are confirmed , 
• Trachea is in centre 
• Movements are equal bilaterally. 
• Apex beat felt in Left 5 th ICS , 1 cm lateral to the midclavicular line .

AUSCULTATION 

• S1S2 Heard 
• No Murmurs 

PER ABDOMEN 
 
• Scaphoid 
• No engorged veins , sinuses , scars 
• No visible epigastric pulsations 
• Soft and NonTender
• No organomegaly 
• Tympanic note heard all over abdomen 
• Bowel sounds +

CNS 

• HMF - Intact 
• Speech - Normal
• No signs of Meningeal irritation
• No Focal neural deficit  
• Sensory and motor system - Normal 
• Cranial nerve - Intact 
• Reflexes - Normal 
• Gait - Normal 
• Cerebellum - Normal 
• GCS 15/15


PROVISIONAL DIAGNOSIS

? AKI on CKD 
? Pulmonary TB
? Heart failure 
? Massive pleural effusion 

INVESTIGATIONS 

Hemogram 
 
                                     RFT 

LFT 

Serum electrolytes 
ABG 

Dengue NS1 
Bleeding and clotting time 
HBsAg
HIV
LDH
Serum osmolality
APTT

Fever chart 



XRay 

15/12/2022 
16/12/2022
18/12/2022 


Final Diagnosis

CKD on MHD 
2° NSAID abuse 




Comments

Post a Comment

Popular posts from this blog

PREFINAL PRACTICAL EXAM

Image
40 YEAR MALE WITH PAIN AND DISTENSION OF ABDOMEN , DECREASED URINE OUTPUT SINCE 2 DAYS  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. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome  I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan • A 40 year old male pt , farmer by occupation resident of Nalgonda came with  Chief complaints  Pain abdomen 2 da...
Read more

48 F SOB 7 days & Pedal oedema 5 days

Image
Im presenting a case of 48 year Female House wife ,  resident of Narketpally  came to opd with  CHIEF COMPLAINTS  Shortness of breath 7 days  Pedal oedema 5 days  HISTORY OF PRESENT ILLNESS  Patient was apparently asymptomatic 1 week ago then she developed shortness of breath which was sudden onset Grade 3 and progressed to Grade 4 ( NYHA CLASS 4 )  Patient also complaining of pedal oedema B/L pitting type , which is extending upto ankle. Grade 3  Patient also complaining of cough ,insidous onset  non productive , not associated with sputum , no diurnal variation . H/o Orthopnea  No H/o PND  N/o H/o Chest pain , palpitations  History of past illness 4 years ago  Patient had admitted with  the similar complaints of pedal oedema & noticed deranged renal  parameters & diagnosed CKD  for which they treated symptomatically with medications  2 years ago  Pedal oedema & treated symtomatic...
Read more

OSCE & LEARNING POINTS

Image
OSCE  • Which is the better afterload reducing drug? One of the classes of drugs commonly used to reduce afterload is vasodilators. Afterload refers to the resistance the heart has to overcome to eject blood into the systemic circulation. Vasodilators help dilate blood vessels, reducing this resistance and making it easier for the heart to pump blood. Several types of vasodilators are used for this purpose: 1. **Angiotensin-Converting Enzyme (ACE) Inhibitors:**    - **Examples:** Enalapril, Lisinopril, Ramipril.    - **Mechanism:** Inhibit the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. This leads to vasodilation and reduced afterload. 2. **Angiotensin II Receptor Blockers (ARBs):**    - **Examples:** Losartan, Valsartan, Irbesartan.    - **Mechanism:** Block the action of angiotensin II on its receptors, resulting in vasodilation and decreased afterload. 3. **Calcium Channel Blockers:**    - **Examples:...
Read more