Final exam long case                                     

Hallticket No. : 1601006160

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 

 40 year old male, labourer by occupation, low socioeconomic status from narketpalli came to opd with 

Cheif complaints:

▪︎Fever since 10 days

▪︎Breathlessness since 7 days

▪︎Chest pain since 4 days

History of present illness:

Patient was apparently asymptomatic 10 days back, then developed

low grade fever on and off since 10 days  not associated with chills and rigor, shows no diurnal variation and relieved on medication, and 

Breathlessness was insidious in onset which used to be grade 2(MMRC) has progressed to grade 4 since last 4 days with no postural or diurnal variation associated  with generalised weakness and  followed by 

Cough since 7 days, associated with moderate amount of purulent sputum mixed with saliva which is white in colour with no postural variation and

 

Chestpain on left side on inspiration and coughing since 4days which was non radiating and relieved on lying down.

No complaints of Palpitation, syncopal attack, , haemoptysis, recurrent sore throat, hoarseness, choking episode, joint pains, burning micturition,loose stools,constipation,Nausea,Vomiting.

Past history 

Not a Known case of dm, hypertension, epilepsy, asthma, CVD, TB, thyroid disease

Family history:

 None of patients attenders have similar symptoms, or have asthma, TB, hypertension, or significant co morbidity.

Personal history:

▪︎Diet mixed

▪︎Appetite decreased

▪︎Sleep adequate

▪︎Bladder and bowel movements are regular

▪︎Chronic smoker since 14yrs 16-18 beedis/day

▪︎Chronic alcoholic since 10yrs and consumes 90ml/day.

General examination:

I have taken the informed consent of the patient before examining.

Patient was examined in supine and sitting position and is 

 conscious , coherent, cooperative , well oriented to time place and person, has  generalised wasting of muscles and is comfortable on bed.

There is no  pallor, icterus, cyanosis koilonychias, clubbing, lymphadenopathy, pedal edema

 JVP is not elevated, hepatojuglular reflex absent.

 Vitals:

▪︎Temperature :Afebrile,98 F

▪︎Respiratory rate- 40  cycles per minute

▪︎Pulse rate 100 beats/min regular in rhythm character volume 

▪︎Blood pressure 90/70 mmHg left arm in sitting position.

▪︎Spo2 98% on room air.

Systemic examination:

Respiratory system: 

1. Upper airway

Nose normal alae Nasi, septum

Oral cavity teeth pharynx normal no sinus tenderness

2. Examination of chest

INSPECTION

Shape of chest is elliptical

Both the shoulders appear to be at the same level

Trachea appears to be central

Apical impulse is not visible

Skin over chest is normal

Trail sign is absent 

Hollownesss in supraclavicular and infra clavicular fossae  

Movements of respiration:

Tachypnea is present and abdomino thoracic respiration

 PALPATION

No local rise of temperature

No tenderness

Chest is expanding equally on both sides

Tactile vocal fremitus is increased infra axillary infra scapular areas on both sides

No palpable thrills crepitation pleural rub

PERCUSSION

Direct percussion on clavicle, sternum and Manubrium is resonant 

Kronig isthmus resonant both sides

Indirect percussion(left) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-6 intercostal spaces are resonant, 5-7 intercostal spaces dull, posterity 9th intercostal space dull

Traube space is dull.

Indirect percussion(right) anteriorly mid claviclular line 2-6 intercostal spaces are resonant. Laterally mid axillary line 4-7 intercostal spaces are resonant. posterity 9th intercostal space resonant.

AUSCULTATION

Left side infra clavicular, mammary, supra scapular,  normal vesicular breath sounds, decreased bronchial breath sounds at infra axillary, scapular, infra scapular areas. 

Crepitations at infra scapular area

whispering pectoriloquy is present.(vocal resonance increased)

Right side infra clavicular, mammary, supra scapular, infra axillary, infra scapular areas-vesicular breath sounds

Other system's examination 

CNS - no facial asymmetry all reflexes are normal 

CVS- S1 S2 heard no added murmurs

ABDOMEN - abdomen is scaphoid with no organomegaly

INVESTIGATIONS:

Chest xray:

Grbs 650 mg/dl 

Urine for ketones positive 

Diagnosis:

This could be a case of diabetic  ketosis (denovo detected diabetes)with left lobe consolidation with chronic calcific pancreatitis 

 

                           Short case

Hall ticket no.:1601006160

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

 A 55year old male toddy climber by occupation, hailing  from miryalaguda came to the opd with 

Chief complaints: 

1)pain abdomen since 10days

2) Fever since 7 days 

3)pedal edema since 7 days 

HISTORY OF PRESENTING ILLNESS:

                       Patient was apparently asymptomatic 10 days back and later developed 

-severe pain abdomen in the right upper quadrant region of abdomen ,which was sudden in onset,gradually progressive , dragging type and non radiating pain.It is aggravated on standing position and relieved for sometime upon taking medication.Not associated with nausea, vomiting,loose stools.

-And then later developed fever since 1 week which was high grade, continuous type and associated with chills and rigor. Relived mildly on taking medications.

 It is not associated with Cold,cough, shortness of breath,neck pain,giddiness,headache and sweating. 

No complaints of chestpain, palpitations and burning micturition.

He subsequently developed pedal edema in legs since 1week which is progressive in nature and seen at ankles .

PERSONAL HISTORY:

Appetite -decreased since 1 week

  Bowel and bladder-Regular

  Micturition-normal

  Addictions- 

toddyconsumption- 1litre/day since 30years

Tobacco in the form of beedi- 10/day since 30years

GENERAL EXAMINATION:

 consent has been taken before examining the patient

Patient is concious,coherent and cooperative sitting comfortably on bed .

He is well oriented to time, place and person and is 

moderately built and moderately nourished.

VITALS :

Temperature : afebrile

Pulse: 76 beats per min 

Regular ,No radio radial delay .

Blood pressure: 110/80 mm hg

Respiratory rate : 16 cycles /min

JVP  is normal 

Pallor : absent 

Icterus 

Mild icterus on sclera 

clubbing : absent 

Koilonychia : absent 

Lymphadenopathy: absent 

Edema : pedal edema which is progressive in nature noted in lower limbs Up to ankle.

ABDOMINAL EXAMINATION

On inspection

Shape of abdomen : Normal 

Umbilicus is inverted and central.

Movements : All the quadrants are moving equally with respiration.

Scar is present on RUQ : pig tail catheter is placed.

PALPATION:

Tenderness is noted in right upper quadrant .

There is no palpable mass in the abdomen .

Liver is not palpable .

Spleen is not palpable .

PERCUSSION:

Liver span is 11 cm.

No free fluid in the abdomen .

AUSCULTATION:

Bowel sounds are heard on auscultation 1 gurgling for every 7 secs 

CVS EXAMINATION:

S1, S2 heard.

RESPIRATORY EXAMINATION:

 Percussion  right infra axillary & infra scapular stony  dull note 

Auscultation  decreased air entry in right infra axillary & infrascapular

INVESTIGATION:

CBP :

Decrease in lymphocyte count.

chest x ray 

Right pleural effusion.

PROVISIONAL DIAGNOSIS:

Based on history , examination followed by investigations my probable diagnosis is liver abscess