1st internal examination

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CKD CASE

CKD CASE 20,06,2022 CASE SCENARIO  Pt aged 70 years came to opd with chief complaints of flank pain and decreased urine output  HISTORY OF PRESENT ILLNESS  Since a week pt has flank pain and decreased urine output   HISTORY OF PAST ILLNESS Pt was asymptomatic 4years back than he met with an accident for which he has been taking medication for pain as post operative medication for pain as a result of chronic use of pain medication pt's kidneys got gradually damaged which resulted in kidney failure  TREATMENT HISTORY  patient is on hypertensive therapy since 3 years and pain killers  PERSONAL HISTORY  Regular bowel habbit  Mixed diet  Decreased urine out put  PHYSICAL EXAMINATION  .patient is conscious,coherent ,and cooperative  .moderately built and moderately nourished  .No signs of --pallor                           .icterus                           .clubbing                           .cynosis     .no edema present    .  VITALS   .Temperature-:98.4F   .pulse rate     -:86   .Rp 
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HEART FAILURE WITH MID RANGE EJECTION FRACTION( EF 44%) WITH RIGHT LOWER LOBE COLLAPSE WITH BRONCHIECTASIS WITH RIGHT MIDDLE LOBE PLEURAL EFUSION WITH CHRONIC PANCREATITIS WITH SEPSIS WITH GRADE 2 BED SORE WITH K/C/O DM II SINCE 20 YEARS WITH K/C/O CAD-S/P: PTCA DONE 2 YEARS AGO D9-S/P: TRACHEOSTOMY

Case History and Clinical Findings  PATIENT CAME WITH C/O LOWER BACK ACHE SINCE 3 WEEKS RADIATING TO LEFT LOWER LIMB  HOPI:PATIENT WAS APPARENTLY ASYMPTOMATIOC 3 WEEKS BACK SINCE THEN, PATIENT COMPLAINTS OF LOWER BACK ACHE WHICH IS SUDDEN ONSET,NON PROGRESSIVE,AGRAVATES ON MOVEMENT RELEIVES ON REST H/O TRAUMA(SLIP AND FALL FROM STEPS) 3 WEEKS BACK ,WAS TAKEN TO OUTSIDE HOSPITAL FOUND TO HAVE L5 BURST FRACTURE ON CT PELVIS AND CAME HERE FOR FURTHER MANAGEMENT NO H/O LIFTING OF HEAVY WEIGHTS,FEVER BURNING MICTURITION BOWEL AND BLADDER INCONTINENCE PAST HISTORY OF RIGHT PROXIMAL FEMUR FRACTURE AND DONE IMILN 10 YEARS BACK. H/O PTCA DONE ONE AND HALF YEAR BACK AND IS ON REGULAR MEDICATION  K/C/O DM II SINCE 20 YEARS AND IS ON T. METFORMIN 500 MG + T. VOGLIBOSE 0.2 MG + T. GLIMIPERIDE 2 MG GENERALEXAMINATION:  PATIENT IS CONSCIOUS,COHERENT AND CO OPERATIVE NO SIGNS OF PALLOR,ICTERUS,CLUBBING,CYANOSIS,EDEMA AND LYMPHADENOPATHY  VITALS: TEMP:AFEBRILE BP: 110/80MMHG PR:80BPM RR:18CPM  SYSTEMIC
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DIABETIC KETOACIDOSIS

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A50 yr old female came to GM OPD with chief complaints of fever, vomiting, difficulty in breathing. HISTORY OF PRESENTING ILLNESS:- patient was apparently asymptomatic 2 weeks back then she developed fever of low grade with vomiting 4 episodes per day which is non-bilious, non-projectile. HISTORY OF PAST ILLNESS:- K/C/O- DM since 20yrs K/C/O- HTN since 20yrs. Not a K/C/O of TB, ASTHMA, EPILEPSY TREATMENT HISTORY:- METFORMIN since 20yrs TELMISARTAN since 20yrs PERSONAL HISTORY:- Diet- mixed Appetite- normal Bowel and bladder habits- regular Burning micturition No addiction FAMILY HISTORY:- Not significant PHYSICAL EXAMINATION:- #GENERAL:- No pallor No icterus No cyanosis No clubbing No lymphadenopathy Vitals:- B.p- 140/90mmHg Pulse-  Temp- Afebrile Respiratory rate- 18/min #Systemic examination:- CVS- S1,S2 heard           No cardiac murmurs           No thrills Respiratory system- dyspnoea present                                       No wheeze                                       Pos
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