PREFINAL PRACTICAL EXAM

40 YEAR MALE WITH PAIN AND DISTENSION OF ABDOMEN , DECREASED URINE OUTPUT SINCE 2 DAYS 


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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 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 days 
Vomitings 1 day 
Decreased urine output 1 day 
No urine output 8hrs 

History of present illness 
Patient was apparently asymptomatic when he was 7 years old with a swelling on the midline lower lumbar region 2x2 cm on midline spine . 
Since then patient complaining of involuntary urination frequently .
Patient used to use intermittent urinary catheter frequently to drain urine by himself 
Patient was asymptomatic in between,  on 30/10/2023 patient had complaints on pain abdomen ( epigastric ) which was  insidious onset not radiating gradually proggresing aggrevating on food intake and relieved temporarily on medication . 


3/12/2023 
 Patient complaining of pain abdomen in epigastric and umbulicus region , dragging type sudden onset gradually proggresive aggrevating on food intake and relieved temporarily on medications 
• History of vomiting 1 episode non bilious non projectile not blood tinged not foul smelling food particals as content .
• Decreased urine output since 1 day 
• No urine output since 8hrs 


• patient also complaining of Shortness of breath since 1 day


Past history 

Patient had a swelling of 2x2 cms on midline lower lumbar region for which he underwent surgery .
Since then he had neurogenic bladder and he is having  involuntary dribbling of urine  for ehich it is managed conservatively
• H/o Hypertension  since 1 year

Family history

No significant family history 

Drug History
 Not on any hypertensive medication.

Personal history
Diet : mixed
Appetite: decreased
Sleep: decreased 
Bowel and bladder movements : irregular (neurogenic bladder).


CARDIOVASCULAR SYSTEM

INSPECTION 

Chest is elliptical shaped, bilaterally symmetrical.

Trachea appears to be central 

Movements are equal bilaterally

JVP:Raised 

No Visible epigastric pulsations 

 No scars or sinuses

PALPATION

All the inspectory findings are confirmed 

Trachea is central 

Apical impulse felt at 5th intercostal space lateral to midclavicular line.

AUSCULTATION 

S1 S2 heard no murmurs 

RESPIRATORY SYSTEM 

INSPECTION

Chest is elliptical shaped,

bilateral symmetrical.

Trachea is central 

Movements are equal bilaterally

No Visible epigastric pulsations 

No scars or sinuses

Apical impulse not seen

PALPATION

All inspectory findings are confirmed: Trachea is central, movements equal bilaterally.

 Antero-posterior diameter of chest >Transverse diameter of chest

Apex beat felt in 6th intercostal space lateral to midclavicular line 

PERCUSSION

Resonant note heard in all  areas bilaterally

AUSCULTATION

Bilateral air entry present – Normal vesicular breath sounds heard



PER ABDOMEN

INSPECTION 

Shape of abdomen appears to normal

No Visible epigastric palpations 

No engorged veins sinus scars

PALPATION 

All inspectory findings conformed

Tenderness + 

No organomegaly

PERCUSSION 

Tympanic note heard all quadrants abdomen

AUSCULTATION

Bowel sounds heard in RIF


CENTRAL NERVOUS SYSTEM

Pt is C/C/C 

HMF - Intact 

Speech & language – Normal 

Memory can recall

No Signs of Meningeal irritation 

Motor and sensory system – Normal 

Reflexes – Normal 

Cranial Nerves – Intact 

Gait – Normal

Cerebellum – Normal  

GCS Score – 15/15

CRANIAL NERVE 

OLFACTORY -  NORMAL (SMELL) 

OPTIC - Normal 

OCCULOMOTOR - Normal

TROCHLEAR  Normal

TRIGEMINAL Normal

ABDUCENS Normal

FACIAL NERVE  Normal

VESTIBULOCOCHLEAR Normal

GLOSSOPHARYNGEAL Normal

VAGUS - Gag reflex present 

SPINAL ACCESSORY Normal shrugging shoulders

HYPOGLOSSAL Normal ( Not deviated )

MOTOR SYSTEM

Bulk -  MUSCLE WASTING IN LL > UL



                         Right.                Left 

Tone      UL     2+                    2+
                                               
              LL.     2+                    2+

Power.   UL       2+                    2+                                                          
                                                  
               LL       2+                    2+

REFLEXES

Corneal - N
Conjuctival - N
Pharyngeal - N
Palatal -N
Abdominal -N
Cremasteric - N

DEEP TENDON REFLEX

Jaw Jerk - N
Biceps - N
Triceps - N
Supinator - N
Knee jerk - N
Ankle jerk- N
Clonus - absent



Position sense:      

                                   Right             Left

Upper Limb              N                        N                                                                               

Lower Limb              N                        N

-Graphaesthesia-Postive

-Stereognosis-Positive

Cerebellar signs:

-Titubation:absent

-Nystagmus:absent

-Dysarthria:absent

-Hypotonia:absent

-Intention tremor:absent

-Coordination

a.Finger Nose test: Normal 

b.Heel Knee test: Normal

c. Dysdiadokokinesia: Negative( able to perform rapid alternative movements)


Signs of Meningeal Irritation:

Neck stiffness: absent 

Kernig’s sign :absent

Brudzinski’s sign:absent

Clinical Images

6/12/2023

Investigations 

Ultrasound 
Provisional Diagnosis 

? High output heart failure 
? Anemia of chronic disease
? AKI  CKD  
? Cauda equina syndrome
? pancreatitis
? Peritonitis 

Treatment 

Fluid restriction < 1.2 L/day 
Salt restriction < 2g/day 
T Lasix 40 mg po/BD
T Shelcal CT po/OD
T Nodosis 1 g po/OD
T Orofer XT PO /OD 
T . Aricamin 0.1mg PO/TID
T. Minipres 2.5 mg PO/OD 
T Senelemas 400 mg PO/BD 
T. Pantoprozole 40 mg PO/OD 
T.Nifidepine 20 mg PO/TID
T . Levocetrizine 5 mg PO/BD
Monitor vitals




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