MEDICINE ELOGS: 1601006181 GENERAL MEDICINE LONG CASE

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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 come up with a diagnosis and treatment plan.

A 65 yr old woman hailing from Miryalguda who is a agricultural labourer by occupation came to the hospital on 23. 04 .21 with chief complaints of vomitings since 4 days

HISTORY OF PRESENTING ILLNESS:

She is a known case of type -2 diabetes since 10 yrs and hypertension since 1 yr and on medication for both

She was apparently asymptomatic 4 days back; then she developed vomitings which were :

Sudden in onset
2 episodes /day
Pale in color
non projectile.
non bilious.
non blood stained
content:- food particles
immediately after eating food.
Associated with constipation and belching since 3 days.

For which she went to miryalguda hospital &was referred to KIMS, Narketpally because of elevated serum creatinine (6.5 mg/dl) and blood urea (171 mg/dl)

She also had pedal edema

Insidious in onset
Since- 3 days

-pitting type

limited to ankles. (grade-1)

Negative history

No history of fever ,loose stools,pain abdomen abdominal distension , headache, dyspepsia dysphagia
No h/o heart burn ,hematemesis meleana
No h/o oliguria , burning micturition ,dysuria
No periorbital puffiness
No h/o Dyspnea, syncope ,palpitation , chest pain

PAST HISTORY

no history of similar complaints in the past

no history of tb , bronchial asthma, epilepsy, thyroid abnormalities

PAST SURGICAL HISTORY ::

underwent hysterectomy 20years back

FAMILY HISTORY:

No similar complaints in other family members
No history of tuberculosis/ bronchial asthma / epilepsy/hypertension

PERSONAL HISTORY

diet: mixed
appetite: decreased
sleep: adequate
bladder movements : normal& bowel movements decreased
no addictions

MENSTRUAL HISTORY :

attained menopause 20yrs back

children 3

DRUG HISTORY

On medication for

- Diabetes : Inj human actrapid insulin 200-x- 750 since 7 years

- Hypertension for 1 year

Clindine trio
Cilndepine 10mg
Olmesartam 20 mg
Chlorthalidone 12.5 mg

- Pedal edema

Torsemide 10 mg

No known drug allergies

TREATMENT HISTORY

1) IVF - NS

2)iv - lasix

3) iv-zofer

4) iv - pantop

5) inj- human actrapid insulin HAI

6) pro-cremaffin

GENERAL EXAMINATION:

informed consent obtained
conscious, coherent, cooperative
well oriented to day, date, time & place
moderately built & nourished

pallor- no signs of pallor
icterus - no signs of icterus
cyanosis - no signs of cyanosis
clubbing - absent
koilonychia - absent
lymadenopathy- absent
pedal edema - present

VITALS

Afebrile
Pulse Rate : -70 bpm

- normal in character

-regular in rhythm

-no radio radial delay radioofemoraldelay

-normal volume

BP: 160/80mm hg in left arm in supine position
RR: 20 cpm
SPO 2: 98% in room air

SYSTEMIC EXAMINATION

UPPER GIT EXAMINATION

Oral Cavity:

Lips normal
teeth normal
gums normal
palate normal
oropharynx normal
cheek buccal mucosa normal
tongue normal
breath normal

Abdomen Examination::

Inspection

shape of abdomen : normal (scaphoid)

flanks : not full
no venous prominence
Umbilicus:

-central in position

-normal (no discharge or hernia seen)

Skin over abdomen:

-no signs of scar ,sinuses ,ulcers

-no pigmentation, striae

-no localised swellings

-no visible pulsations

movements of abdomen : all quadrants are moving with respiration
no visible peristalsis
hernial orifices: free

Palpation

Superficial:

no local rise of temperature
no tenderness
guarding : absent
rigidity : absent

Deep Palpation :

LIVER :

liver span: normal
no tenderness

SPLEEN :

spleen not palpable

no rebound tenderness

Percussion

Tympanic note heard;

Dull note heard over the upper border of liver and spleen.

Liver span is normal

Auscultation

normal bowel sounds heard

OTHER SYSTEMS

CVS:

S1 S2 heard

JVP normal

Respiratory system

Normal vesicular breath sounds heard

CNS-

Higher Mental functions : intact

Motor System : Reflexes preserved

Babinskis sign : Flexor response

Sensory system : Cranial nerves intact

From the history and examination, differential can be Acute GE, acute Gastritis, Bowel obstruction, endocrine or metabolic causes like gastroenteritis,gastric or bowel obstruction , Uremia etc.

INVESTIGATIONS:

Hemogram