GENERAL MEDICINE CASE PRESENTATION 


CASE SCENARIO 

A male 55 years old patient farmer by occupation came to opd with chief complaints of numbness of hands, knee pains, tremors 

HISTORY OF PRESENT ILLNESS 

Numbness of hands and and nerve weakness,pain in the knee since 10 years 

 HISTORY OF PAST ILLNESS 

Pt was met with an accident 10 years back resulting in cervical spinal injury 

TREATMENT HISTORY 

Pt is on pain medication since 10 years 


PERSONAL HISTORY 

Irregular bowel habit 
Normal bladder movement 
Mixed diet 
Non smoker 
Non alcoholic 

PHYSICAL EXAMINATION 


.patient is conscious,coherent ,and cooperative 


.moderately built and moderately nourished 


.No signs of --pallor 


                         .icterus


                          .clubbing


                          .cynosis


    .no edema present 

   .no lymphadenopathy 

  .  VITALS

  .Temperature-:98.4F

  .pulse rate     -:86

  .Rp                   -:20/min

  .Bp                    -:120/80mm/Hg

  .spo2                 -:96



SYSTEMIC EXAMINATION-:



CARDIOVASCULAR SYSTEM 

       .S1 S2 HEARD

       .No murmers


RESPIRATORY SYSTEM 


.Position of trachea is central 

.breath sounds -normal vesicular breath sounds 



ABDOMEN 


.Shape- scaphoid 

.no tenderness

.no palpable mass

.no free fluid 



.spleen and liver not palpable 


CENTRAL NERVOUS SYSTEM 


.Intact 

.no focal defects 

.no abnormality detected 


CLINICAL IMAGES 


   







            



   



Comments

Post a Comment

Popular posts from this blog

24.prannai reddy

Image
  GENERAL MEDICINE E-LOG October 04, 2021 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.  NOTE: This is an ongoing case, the ELOG will be updated as and when we get the new information.  CHIEF COMPLAINT: A 65 year old male came to opd with the chief complaints of  Pedal edema and  Dyspnea on exertion( Grade III) since 10 days  HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 10 days back, then he developed pedal edema and he was having dyspnea on exertion which is of grade III.  No bleeding manifestation No c/o burning micturition  No c/o cough, cold, headache HISTORY OF PAST ILLNESS: He was diagnosed with Acute K...
Read more

ALTERED SENSORIUM SECONDARY TO ? SEPTIC ENCEPHALOPATHY WITH UTI ? TB MENINGO ENCEPHALIIS WITH PRE RENAL AKI ON CKD WITH HEALING GLUTEAL ABSCESS WITH HTN WITH LATE ONSET PSYCHOSIS WITH ANEMIA OF CHRONIC DISEASE WITH GRADE II BEDSORE WITH HYPOKALEMIA

Case History and Clinical Findings  PT C/O FEVER,ALTERED SENSORIUM,LOSS OF APPETITE SINCE 2 DAYS. PT WAS APPARANTLY ASYMPTOMATIC 2 DAYS AGO THEN SHE HAD FEVER WHICH WAS HIGH GRADE, NOT ASSOCIATED WITH CHILLS, RIGORS.RELIEVED WITH MEDICATION.NO DIURNAL VARIATION. ALTERED SENSORIUM SINCE 2 DAYS. IRRELEVANT BLACK OUT , NOT ABLE IDENTIFY ATTENDERS. NO H/O LOSS OF CONSCIOUSNESS,INVOLUNTARY MOVEMNENTS, WEAKNESS IN BOTH UPPER AND LOWER LIMBS.LOSS OF APPETITE PRESENT N/H/O CHEST PAIN,SOB,PALPITATIONS,PEDAL EDEMA. N/H/O COUGH,BURNING MICTURITION K/C/O HTN ON TAB.ATENOLOL K/C/O CKD ON CONSERVATIVE MANAGEMENT K/C/O AKION CKD SECONDARY TO RUPTURED GLUTEAL ABSCESS WITH K/C/O LATE ONSET PSYCHOSIS H/O BLOOD TRANSFUSION- FFP TRANSFUSION GENERAL EXAMINATION- PT IS DROWSY AROUSABLE WITH DEEP PAIN STIMULATION NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,OEDEMA.  BP: 100/60MMHG PR : 98BPM RR : 24 CPM SPO2 : 97% GRBS : 148 MG% I/O : 2500/1300 SYSTEMIC EXAMINATION  CVS : S1 S2 HEARED ,N...
Read more

ALTERED SENSORIUM- HYPOACTIVE DELIRIUM ? SECONDARY TO DYSELECTROLYTEMIA CKD (DIABETIC NEPHROPATHY) K/C/O DM2 DENOVO HTN

Case History and Clinical Findings  54 year male came to casualty on 27-10-22 with complaints of hiccups since 5 days and altered sensorium since morning  HOPI:  Pt was apparently asymptomatic 5 days back then he had continuous hiccups since 5 days Altered sensorium since morning (He had ? up rolling of eyeballs and frothing 1 episode in the morning not associated with any involuntary movements or involuntary micturition or tongue bite) No h/o fever,headache,giddiness,vomiting No other complaints  Past history :  He had similar episode 6 months back2 months back he was admitted in hospital with similar complaints and was found out to have dyselectrolytemia - treated symptomatically K/c/o DM since 7 years ( he had trauma 5 years back to foot which was not healing properly so he went to the hospital and was diagnosed as diabetic) Initially he took medication but his sugars were not under control Then he was switched to insulin under doctor’s advice 20U in the morn...
Read more