General medicine final practical short case

 April 28,2021

Short case - GENERAL MEDICINE 

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 

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

This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome."

 SHORT CASE

 45 year old male, resident of  ramanapet, farmer by occupation, came to the Opd, with chief complaints of 

shortness of breath since one year.

Bilateral pedal edema since three months.

 HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic one year back then he developed, shortness of breath, which was insidious in onset gradually progressive from grade two to grade four, aggravated on lying down and on exertion and relieved medications.

The patient also complains of pedal edema since 3 months, insidious in onset, gradually progressive from involving the ankle to involving the whole limbs, pitting type,  aggravated by walking , slight in the morning and more by the end of the day which relieved on elevating the legs. 

Patient also gives a history of decreased urine output since 1 month, insidious onset,  gradually progressive.

There's history of weight loss.

No h/o paroxysomal nocturnal dyspnea.

No history of cough and expectoration, chest pain, no history of palpitations and syncope .No history of fever, sore throat, joint pains. No hemoptysis, hematemesis, no history of Jaundice, no history of burning micturition.

PAST HISTORY:

He had a road traffic accident 3 years back, had a surgery on right leg and was on medications for one year (analgesics).

He is a known case of hypertension since 2 years, diagnosed when he went to a camp- was using nicardia 20 MG thrice daily and stop taking tablets since one year.

The patient is on dialysis since 10 months.

He is not a known case of diabetes, TB asthma, epilepsy.

PERSONAL HISTORY:

He has a mixed diet.

Appetite- normal

Sleep- disturbed 

Bladder- irregular

Bowel movements- regular

Addictions- chronic alcoholic for 20 years stopped drinking since last three years.

FAMILY HISTORY:

There is no significant family history.

DRUG HISTORY:

The patient used analgesics for a year.

 Used nicardia 20 MG for Hypertension.

GENERAL EXAMINATION:

The patient is conscious, coherent, Cooperative, moderately built and nourished.

Pallor - present

There are no signs of icterus, cyanosis, koilonychia, clubbing and lymph adenopathy.

Edema- present.

JVP- raised.

A-V fistula- felt

VITALS:

PR- 82bpm,regular,normal volume

BP- 130/80mm Hg right arm, sitting position

RR- 24cpm

TEMP- afebrile.

Local examination of cardiovascular system

Trachea appears to be Central 

Shape of the chest - normal

Apical impulse visible, appears to be shifted from its normal

no visible scars, sinuses, dilated veins in any part of the thorax, no bony abnormalities.

Palpation:

All Inspectory findings are confirmed.

Trachea is central confirmed by 3-finger test.

Apex beat is shifted outwards and downwards, 4 to 5 cm lateral to mid clavicular line in 6th intercoastal space.

no palpable heart sounds and no palpable murmurs. 

Percussion:

Right heart border shifted 1 cm right  from the right sternal border.

Left heart border shifted 4 to 5 cm lateral to midclavicular line.

Auscultation:

S1 S2- heard

No murmurs.

Per Abdomen:

Inspection-

Abdomen- distended 

Umbilicus -Central in position and slit like

flanks are full

no sinuses, scars or visible pulsations 

hernial orifices are free.

Palpation 

no local rise in temperature 

no tenderness  

no guarding and rigidity 

no palpable masses.

Percussion:

shifting dullness- present

liver span-normal

Auscultation:

bowel sounds are heard.

Respiratory system :

bilateral air entry- present

normal vesicular breath sounds heard 

basal crepitations present in both the lung fields.

Central nervous system- normal.

INVESTIGATIONS:

CBP- 

Hemoglobin- reduced

PCV- reduced 

RBC count -reduced

CUE-  

Albumin in urine

RANDOM BLOOD SUGAR-

X-RAY:

ECG-

RFT:

 Serum urea and creatinine- raised.

LFT:

SERUM IRON:

USG ABDONEN:

Grade-II renal parenchymal disease

PROVISIONAL  DIAGNOSIS:

CHRONIC KIDNEY DISEASE WITH HEART FAILURE.

TREATMENT: 

Salt and fluid restriction

Tab. Nicardia 10mg T.I.D

Tab. Lasix 40mg B.D

Tab. Arkamin 100mg

Tab. Unifer

Capsule. Gel cal D3

Final examination general medicine

50 YEAR OLD FEMALE WITH WEAKNESS ON LEFT SIDE OF BODY

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 diagnosis with a treatment plan. 

 This is an online E log book to discuss our patient’s de-identified health data shared after taking her guardian’s signed informed consent. 

A 50 year old right handed lady, who is a farmer by occupation, hailing from Vardhamanapeta came with 

Chief Complaints:  

1. Weakness of left upper limb and lower limb since 5 days. 
2. Slurring of speech since 5 days. 
3. Deviation of angle of mouth to right since 5 days. 

History of Presenting illness: 

She was apparently asymptomatic 5 days back. 

On 20th of April,

She woke up and did her routine activities like brushing and cooking food. 

At 8:30 AM, she went to wash her face and experienced weakness of Left Upper limb and Lower limb, which was sudden in onset, leading to a fall associated with loss of consciousness from which she recovered spontaneously 5 minutes later. 

She complains of giddiness at the beginning of attack. 

She also experiences slurring of speech which was sudden in onset and gradually progressive. 

This is associated with drooling of saliva and deviation of angle of mouth towards right side while speaking, eating and showing teeth. 

She is unable to comb her raise and mix her food.

She is unable to squat and has difficulty in wearing slippers. 

She was brought to the hospital at 6pm. 

There is no history of involuntary movements. 

No history of loss of bowel and bladder control. 

No history of vomiting, convulsions, double vision, nasal regurgitation or nasal intonation. 

No history of head injury, fever, palpitations, chest pain or breathlessness. 

No history of similar attacks in the past. 

No history of memory impairment. 

No history of waxing or waning of symptoms. 

Past History: 

No history of similar complaints in past. 

She is a known case of Hypertension and diabetes mellitus since 8 years and is on medication for it. 

There is no history of tuberculosis, bronchial asthma, COPD, rheumatic fever or epilepsy. 

No history of recent weight loss. 

Drug history: 

She has been taking the following drugs since 8 years: 

• Telmisartan 5mg 
• Prazosin 5mg 
• Teneligliptin 
• Glimepiride, Voglibose and Metformin 

No history of any drug allergies. 

Family history: 

No history of similar attacks in other family members.

Personal history:

Diet: mixed 

Appetite: normal

Sleep: adequate 

Bowel and bladder movements: regular 

No addictions 

General examination: 

The patient is conscious, coherent and cooperative. 

She is moderately built and moderately nourished. 

She is lying in supine position in the bed. 

Temperature: afebrile 

Pulse: 78/minute, regular, normal in volume, no thickening of arterial wall felt, No radio radial or radio femoral delay seen. 

Blood Pressure: 130/90 mm Hg recorded on right arm in supine position. 

Respiratory rate: 18 cycles/minute

Pallor: absent 

Icterus: absent

Cyanosis: absent 

Clubbing: absent 

Koilonychia: absent

Lymphadenopathy: absent 

Edema: present and of pitting type 

Systemic examination

Central Nervous System examination

The patient is conscious, alert and cooperative. 

A) Higher mental function 

She is oriented to time, place and person.

Her speech is slurred. 

Her comprehension is intact and repetition is normal. 

B) Cranial Nerves

1. Olfactory (I): can perceive smell
2. Optic (II): Visual acuity- CF 2 in both eyes and field of vision- normal 
3. Occulomotor(III), Trochlear(IV),Abducens(VI) : External ocular movements full in all directions. No nystagmus and no ptosis. Pupil reactive to light. 
4. Trigeminal Nerve: Sensation over face present. Corneal reflex and Jaw jerk present. 
5. Facial Nerve (VII): deviation of angle of mouth to right side. Loss of nasolabial fold on left side. Frowning present, upper half of face escaped. Drooling of food particles on left side. 

1. 
   
   
   
2. Vestibulocochlear nerve(VIII): audition intact on both sides. 
3. Glossopharyngeal(IX) and Vagus(X): gag reflex present. 
4. Accessory(XI) and hypoglossal nerve(XII): normal 

C) Motor function

Nutrition: no wasting seen. 

Tone                              R.             L 

Upper limb.                Normal.      Decreased 

Lower limb.                Normal.      Decreased 

Muscle power 

Upper limb.              5/5.               1/5 

Lower limb              5/5.                3/5 

No involuntary movement. 

D)Sensory function

Superficial: pain, touch and temperature are intact. 

Deep: vibration sense, muscle sense, pressure sense, joint sense and position sense are intact. 

Cortical: one point localization, two point discrimination, stereognosis and graphaesthesia intact 

E) Reflexes 

Superficial 

                               Right.           Left 

Abdominal              Normal.       Lost

Plantar reflex          Flexor.        Extensor

Deep

Biceps jerk.           +2.               +2

Triceps jerk.          +2.                +1

Supinator jerk.      +1.                 -

Knee jerk.             +2.                +2 

Ankle jerk.              -                    -

Clonus                  Absent.        Absent 

Visceral

 Swallowing: normal 

Bladder: normal 

Bowel: normal 

F) Trophic Changes: absent 

G) Cerebellar function

Dysdiadochokinesia: absent. 

No nystagmus 

H)Autonomic function: normal 

Cardiovascular system

Peripheral arterial pulses: present 

Carotid pulsations present, no Bruit heard. 

S1 and S2 heard. No murmurs. 

Respiratory System

Shape of chest: Elliptical

Movement of chest: normal

Trachea: central in position 

Percussion: resonant on both sides

Breath sounds: vesicular 

Vocal resonance: normal on both sides 

Adventitious sounds: none 

Gastrointestinal Tract

Mouth, tongue, teeth, gum: NormalBowel sounds heard 

Investigations 

1. Chest X ray 

2. CT Head

No hyperintensities or hypointensities seen.

3. ElectroCardioGram

Normal with heart rate 90 beats per minute. 

Treatment

1. Pharmacotherapy:

• Rosuvastatin ( HMG CoA inhibitor) given to decrease the risk of stroke in the future. 
• Pregabalin and Methylcobalamine: to treat nerve damage 
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2. Physiotherapy 

                  

Provisional diagnosis: 

Based on the history, 

• Anatomical localization: Infarct of Middle cerebral artery supplying the Right Internal Capsule. It is an upper motor neuron lesion. Upper motor neuron lesion of the VII nerve leading to facial nerve palsy on the same side of hemiplegia suggests that the lesion is above the pons. 
• Pathological abnormality: Ischemia 
• Biochemical abnormality: free radical release due to hypoxia 
• Physiological abnormality: weakness of left upper limbs, lower limbs and left side of face.