GENERAL MEDICINE CASE

Sravanibekkam 15 
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 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 

INVESTIGATIONS
ABG:
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

PROVISIONAL DIAGNOSIS: 

L5 unstable burst fracture associated with posterolateral corner injury (PLC). 



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