M.B.B.S Final Practical Examination Short Case - 1701006038

D. Gaurav Singh
1701006038

DE-IDENTIFIED CONSENT FORM :
A 46 year old male came to casuality with chief complaints of 

-burning micturition since 10days

-vomiting since 2days (3-4 episodes)

-giddiness and deviation of mouth since 1day

History of presenting illness:

Patient was apparently asymptomatic 10years back, he complained of polyuria for which he was diagnosed with Type 2 diabetes mellitus he was started on oral anti diabetic medication, 3years back oral medication were converted to insulin.

20days back he developed vomiting containing food particles, non bilious,non foul smelling(3-4 episodes),later he complained of giddiness and deviation of mouth for which he was brought to our hospital 

No history of fever/cough/cold 

No significant history of UTIs

Past history:

10years back patient complained of polyuria for which he was diagnosed with Type 2 Diabetes Mellitus, he was started on oral hypoglycemic agents(OHA) 10years back

3years back OHAs were converted into Insulin

3years back he underwent cataract surgery

1year back he had injury to his right leg, which gradually progressed to non healing ulcer extending upto below knee and ended with undergoing below knee amputation due to developement of wet gangrene.


Delayed wound healing was present- it took 2months to heal

Not a known case of Hypertension, Epilepsy,Tuberculosis, Thyroid, Asthama. 

Not on any medication

No history of blood transfusion 

Personal history:

Diet - Mixed

Appetite- normal

Sleep- Adequate 

Bowel and bladder- Regular

Micturition- burning micturition present

Habits/Addiction:

Alcohol- 

Not consuming alcohol since 1 yr.

Previously (1yr back) Regular consumption of alcohol, about 90mL whiskey consumed almost daily.Also 1 month on & off  consumption pattern previously present 

Family history:

Not significant

Vitals during Admission:

BP: 110/80 mmHg

HR: 98 bpm

RR: 18 cpm

TEMP: 99F

SpO2: 98% on RA

General Examination:
Pallor present 

No- icterus,cyanosis,clubbing,koilonychia, lymphadenopathy

No dehydration


Systemic Examination:

CVS: S1S2 heard, No murmurs

RS: BAE+,NVBS

P/A: Soft, Non tender

CNS: 

Reflexes: (Biceps/Triceps/Knee/Ankle/Plantar)Normal

Power: Normal(5/5) in both Upper and Lower limbs

Tone: Normal in both Upper and Lower limbs

No meningeal signs

Investigations:

Culture report:  Klebsiella Pneumonia positive
Pus cells


Provisional Diagnosis: 
 pyelonephiritis  with h/o of Type 2 Diabetes mellitus since 10years and amputation below knee 

Popular posts from this blog

57/M with ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA

Image
April 26, 2023 Cheif complaints and HOPI  A 56 year old male patient who is a resident of koilagudem (nalgonda district)who is a daily wage labourer by occupation brought to the casualty  in unresponsive state at 1:30 Am .patient was found drowsy from 1 pm on 25/04/2023 And suddenly developed seizure like activity associated with slurring of speech,uprolling of eyeballs,stiffness of all four limbs, Associated with involuntary defecation and micturition and found unresponsive.  No h/o fever ,cough. No h/o neck stiffness and projectile vomitings.  No h/o generalised weakness ,tingling,numbness. No h/o head trauma.  Patient was apparently asymptomatic 6 months back then he developed multipleSwellings Over the Cheek, Forearm, legs with dischargingPus with no pain. for which he went to an RMP and he prescribed Antibiotics but it resolves on for some days and then reappears in 10-15days. He also developed swelling on the nose 6 months back the RMP Removed the pus ,Aft...
Read more

MY INTERNSHIP JOURNEY IN GENERAL MEDICINE

Internship 6/3/2023 to 4/5/2023  MY INTERNSHIP JOURNEY IN GENERAL MEDICINE  I'm an intern, posted in general medicine department for 2 months including 2 weeks of psychiatry. First 2 weeks: Posted in Department of Psychiatry: Attended the OPD in department of psychiatry and observed various spectrum of psychiatric disorders in the patients. Studied symptomatology regarding various psychiatric disorder spectrums.  I got to know about the ICD-10 Classification of psychiatry disorders and also DSM Classification of diseases. Done night duties for observation of psychiatry patients of withdrawal syndromes. And learnt how to manage them. Attended the De addiction centre visits and observed the various types of medical, behavioural therapy going on there.  Learnt how to attend rounds for the patients and how to write repeats in the casesheets from post graduates. Typed, studied and submitted the discharge summaries of various patients under department of psychiatry. From t...
Read more

70/F RECENT HYPOGLYCEMIA 2°TO ?SEPSIS WITH CKD WITH TYPE 2 DM SINCE 10 YEARS.May 03, 2023

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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan CHEIF COMPLAINTS AND HOPI: A 70 year old female who is a home maker by occupation who is a resident of chityala was brought to the casualty in altered sensorium.  Patient was apparently asym...
Read more