2K18 BATCH UNIVERSITY PRACTICAL EXAMS DEPARTMENT OF GENERAL MEDICINE - MARCH 2023
2K18 BATCH UNIVERSITY PRACTICAL EXAMS DEPARTMENT OF GENERAL MEDICINE MARCH 2023 S.NO HALL TICKET NO CASE PRESENTATION BLOG LINK CASE PRESENTATION VIDEO LINK 1. 1601006100 https://finalmbbspart2gmpracticals.blogspot.com/2023/03/1601006100-case-presentation.html https://youtu.be/RjXy6VRc0bc 2. 1701006039 https://finalmbbspart2gmpracticals.blogspot.com/2023/03/1701006039-case-presentation.html https://youtu.be/QsBFryWuMYQ 3. 1701006089 https://finalmbbspart2gmpracticals.blogspot.com/2023/03/1701006089-case-presentations.html https://youtu.be/4b-DBdCWoaY 4. 1701006131 https://finalmbbspart2gmpracticals.blogspot.com/2023/03/1701006131-case-presentation.html https://youtu.be/kSCJcPaBMR0 5. 1701006146 https
LONG CASE
Shortness of breath since -10days
Swelling of upper and lower limbs since-6days
Decreased urine output since - 6days
-patient was apparently asymptomatic 1year back the he had shortness of breath which is intermittent type and then he was also diagnosed with CKD 1year back
-10days back he had sudden onset of SOB which is gradeII gradually progressive to grade IV
-orthopnea present
-paroxysmal nocturnal dyspnea present
swelling of both upper and lower limbs .
Lower limb edema which is Pitting type upto thigh
PAST HISTORY:
-History of fall from tree 10 years ago and then onwards he developed backache and neckpain .
-3yrs back he had fever ,cough,loss of appetite for 2months and had been diagnosed with tuberculosis and diabetes.
-he took anti tuberculosis therapy for 6months and on OHA since then.
-SOB with wheeze (since 3 years) on and off and with CKD 1 year ago.
GENERAL EXAMINATION:
patient was conscious, cooperative and oriented to time,place and person
No signs of pallor ,icterus ,cyanosis, lymphadenopathy. -Bilateral pitting edema is present.
B/L pitting edema
VITALS:
TEMPERATURE: afebrile
PULSE RATE: 102 bpm
RESPIRATORY RATE: 30cpm
BLOOD PRESSURE: 150/90 mm hg
SPO2: 97% @ room air
GRBS: 203 mg/dl (N-<140mg/DL)
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM:.
inspection:
-Shape of chest- elliptical
-No engorged veins, scars, visible pulsation
-APEX BEAT @ 6TH intercostal space 1cm lateral to midclavicular line
Auscultation:
S1 and S2 are heard
RESPIRATORY SYSTEM:
inspection:
Shape-elliptical
B/L symmetrical
Both sides moving equally with respiration.
No scars ,sinuses, engorged veins, pulsations
Palpation :
trachea -central
expansion of chest is symmetrical
Auscultation : bilateral air entry present
bilateral infrascapular ,infra axillary crepts present .
INVESTIGATIONS:
Serology:
HCV: NON REACTIVE
RANDOM BLOOD SUGAR: 125mg/dl
RFT:. RFT on 15/3/23
S.UREA: 64mg/dl. ------>140mg/dl
S. CREATININE: 4.3 mg/dl--->5.7mg/dl
S. Na+: 138
S. K+: 3.4
S. Cl-: 104
S. Ca+2: 0.92
-HbA1C: 6.5%
Complete urine examination:
Colour -pale
Albumin -nil
HEMOGRAM. On15/3/23
Hb-12.6. ----. 11.7
Lymphocytes -15 ---. 20
Rbc count. 4.7. ----. 4.4
platelet count-1lakh ---. 1lakh
CHEST X-ray:
ECG:
ULTRASOUND:
USG CHEST:
E/O FREE FLUID NOTED IN BILATERAL PLEURAL SPACES (RIGHT MORE THAN LEFT) . IMPRESSION:
BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT)
LFT:
Total bilirubin- 2.8mg/dl. --->(N-0.2 to 1.0mg/dl)
Direct bilirubin -1.2mg/dl. --->(N-upto0.25mg/dl). Alt -250U/L. --->(N-40U/L). Ast-210U/L. --->(N-40U/L)
ABG:
pH: 7.3.
PCO2: 28.0. Nr-(35-45mmhg)
pO2: 77.4.
HCo3: 13.5. Nr-(22-28)
PROVISIONAL DIAGNOSIS:
ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE (SECONDARY TO DIABETES)
HEART FAILURE.
WITH K/C/O DM II SINCE 3 YEARS
WITH BILATERAL PLEURAL EFFUSION (RIGHT MORE THAN LEFT)
TREATMENT:
1. FLUID RESTRICTION LESS THAN 1.5 LITRES/DAY
2. SALT RESTRICTION LESS THAN 1.2GM/DAY
3. INJ. LASIX 40 MG IV/BD
4. TAB. MET XL 25 MG PO/OD
6. INJ. HUMAN ACTRAPID INSULIN SC/TID
7. INJ. PAN 40 MG IV/OD
8. INJ. ZOFER 4 MG IV/SOS
9. STRICT I/O CHARTING
10. VITALS MONITORING
11. TAB. ECOSPRIN 75 MG OD
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SHORT CASE
29 year old female with sob, edema,facial puffiness.
Patient came to casuality with cheif complaints of -
B/l pedal dema - 20 days
Facial puffiness - 20 days
Breathlessness - 1 day
Hopi:
Patient was apparently asymptomatic 10 years back then was diagnosed with dm-1 and is on insulin mitard (20u-x-16u). -she had 2 episodes of weakness, uncontrolled sugars for which she was admitted for a day &discharged ( 1st episode 5years back and 2nd episode 3 years back respectively). -.on nov
2022 patient was taken to govt hospital i/v/o sob and was diagnosed with denovo hypertension, uncontrolled sugars ( started on ? Htn medication). -.on 2nd jan 2023, she had episodes of vomitings, loose stools and was admitted in aiims & was diagnosed with diabetic nephropathy, htn ,vit d deficiency .
Hyperpigmented lesion on right foot. -6 days back she developed pedal edema and sob which was insidious in onset gradually progressive (grade 2 to 4) associated with orthopnoea and was brought to our hospital as her symptoms didn't subside.
Past history:
K/c/o dm type 1 since 10 years and is on insulin
K/c/o htn from 2 months and on t telma+clinidipine and t metxl
H/o of right eye cataract surgery: 8 years back
Personal history:
Appetite - normal
Diet - mixed
Bowel and bladder - regular
Sleep - adequate
General examination:
Pt is concious , coherent, cooperative.
Pallor: present
Pedal edema - present,pitting type, till knee no icterus,cyanosis,clubbing,
Lymphadenopathy
Vitals on admission:
Pr-113 bpm
Bp- 220/120mm hg
Rr- 26 cpm
Spo2- 72% at ra
Grbs - high
Systemic examination:
1) per abdomen:
Inspection:umbilicus is central and inverted, all quadrants moving equally with respiration,no scars,sinuses, engorged veins, pulsations.
Palpation: soft,non tender.no organomegaly.
Ascultation: bowel sounds - heard
2)respiratory system:
Inspection: shape of the chest is elliptical. B/l symmetrical. Both sides moving equally with respiration..no scars,sinuses, engorged veins,pulsations.
Palpation:no local rise of temperature and tenderness.trachea is central in position.expansion of chest is symmetrical vocal fremitus is normal
Percussion: resonant bil
Ascultation: bae + , nvbs heard
3) cvs:
Inspection: b/l symmetrical, both sides moving equally with respiration,no scars,sinuses, engorged veins,pulsations.
Palpation: apex beat felt in left 5th ics. No thrills and parasternal heaves.
Ascultation: s1s2 +,no murmurs
Diagnosis:
Type 1 dm with uncontrolled sugars (resolving)
With hypertensive emergency (resolved)
And necessary investigations were done, her sugars were found to be high and bp being -220/110mmhg on presentation and was treated symptomatically. Refrrals were taken from endocrinologist i//o high sugars.
-initially for hypertension,she was treated with t. Telma 40mg + clorthalidone 12.5mg and t.metxl 25mg and later on was fixed on t.nicardia 20mg po/bd(8am-x-8pm) .
Follow up after starting treatment;
Bp timeline:
12pm-200/100
3pm-180/90
8pm-160/80
9pm-150/90
Grbs timeline:
6am-494
7am-499
2pm-456
7pm-254
Most recent follow up -
bp time line
1pm-126/73
3pm-124/76
10pm-108/62
GRBS:
1pm-222
8pm-98