GENERAL MEDICINE CASE
Sravanibekkam 15
D_DIMER:
RandomBlood sugar
RFT:
serum electrolytes :
serum osmolality :
Anti HCV antibodies
HBsAg
Prothrombin time
Complete urine examination
Complete blood picture
blood grouping and RH type
Bleeding and clotting time
APTT
Urine for ketone bodies
Hemogram
Troponin -1
HRCT of chest
ECG
Sravani 15
September 14, 2023
Welcome and greetings to every one who are visiting my blog. This is B.Sravani of 8th semester. This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.
Case :
A 55 year old male resident of Nalgonda presented to the causality with lower back ache and radiating pain to the left leg since 3 weeks
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic until 3 weeks ago after which he developed lower ache which is sudden in onset, non progressive, aggravates on movement, relives on rest.
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic until 3 weeks ago after which he developed lower ache which is sudden in onset, non progressive, aggravates on movement, relives on rest.
History of trauma (slip and fall from stairs) 3 weeks ago
The patient was taken to the local hospital where he was found to have L5 burst fracture on CT pelvis.
No history of lifting heavy weights, fever, burning micturition,
PAST HISTORY :
k/c/o DM T2 since last 30 years
K/c/o CAD since 2 years
N/k/c/o of HTN, epilepsy, TB, asthma.
History of PCTA 2 years ago
TREATMENT HISTORY:
Tab. Metformin 500mg
Tab . Roglibose 0.2mg
Tab. glimidipine 2mg
PERSONAL HISTORY :
sleep : adequate
Bowel and bladder : regular
Appetite : normal
Addictions: alcohol occasionally
Allergies : none
GENERAL EXAMINATION:
Bilateral pitting oedema of upper and lower limbs .
no signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy,
Vitals:
Temperature: 98.2°
Pulse rate : 80
Respiratory rate : 18 cpm
BP: 110/80 mm/hg
Spo2: 98% / at RA liters
SYSTEMIC EXAMINATION :
CVS:
Thrills: no
Cardiac sounds: s1,s2 +
Cardiac murmurs : no
RESPIRATORY SYSTEM:
Dyspnoea: no
Wheeze: no
Position of trachea: central
Breath sounds: vesicular
ABDOMEN:
Shape of abdomen : scaphoid
Tenderness: not
Palpable mass: no
Hernial orifice:Normal
Free fluid: no
Bruits: no
Liver: not palpable
Spleen: not palpable
Bowel sounds: yes
CENTRAL NERVOUS SYSTEM:
1. Level conscience: conscious
2. Speech: normal
No history of lifting heavy weights, fever, burning micturition,
PAST HISTORY :
k/c/o DM T2 since last 30 years
K/c/o CAD since 2 years
N/k/c/o of HTN, epilepsy, TB, asthma.
History of PCTA 2 years ago
TREATMENT HISTORY:
Tab. Metformin 500mg
Tab . Roglibose 0.2mg
Tab. glimidipine 2mg
PERSONAL HISTORY :
sleep : adequate
Bowel and bladder : regular
Appetite : normal
Addictions: alcohol occasionally
Allergies : none
GENERAL EXAMINATION:
Bilateral pitting oedema of upper and lower limbs .
no signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy,
Vitals:
Temperature: 98.2°
Pulse rate : 80
Respiratory rate : 18 cpm
BP: 110/80 mm/hg
Spo2: 98% / at RA liters
CVS:
Thrills: no
Cardiac sounds: s1,s2 +
Cardiac murmurs : no
RESPIRATORY SYSTEM:
Dyspnoea: no
Wheeze: no
Position of trachea: central
Breath sounds: vesicular
ABDOMEN:
Shape of abdomen : scaphoid
Tenderness: not
Palpable mass: no
Hernial orifice:Normal
Free fluid: no
Bruits: no
Liver: not palpable
Spleen: not palpable
Bowel sounds: yes
CENTRAL NERVOUS SYSTEM:
1. Level conscience: conscious
2. Speech: normal
INVESTIGATIONS
ABG:
ABG:
PROVISIONAL DIAGNOSIS:
L5 unstable burst fracture associated with posterolateral corner injury (PLC).
Comments
Post a Comment