Elog GM Case 56 Mahendra
GENERAL MEDICINE CASE
Urine Protein: Creatinine ratio:
MRI - BRAIN:
CBP:
Hello all. This is K Mahendra roll no 56,a third semester medical student. This an e log depicting patient centred approach of learning. This log has been created after taking consent from the patient and her family.
Date of Admission: 28-06-2021
A 52-year-old man presented to the OPD with Chief Complaints of abdominal distension from the past 7 days.HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 2 years back, then he had a non healing injury to the right foot which raised a suspicion of Diabetes mellitus. Then they went to neatest medical care and diagnosed with Diabetes mellitus type 2 and was started on Tab. GLIMI M2 OD.
2 years back he complained of Tingling in the upper limbs up to the palms, in the lower limbs up to the knee.
15 Days back patient presented to the casualty with Abdominal Distension NOT associated with pain, No nausea, No Vomiting, No loose stools and was diagnosed with
Alcoholic Liver Disease,
AKI secondary to UTI on CKD, secondary to ? Diabetic nephropathy,
Hepatic encephalopathy grade 2
From the past 7 Days, He Complains of Abdominal Distension.
From the past 5 days, he complains of Constipation and has not passed stools since 5 days.
He also complains of altered Sleep patterns from the past 5 Days
He has hiccups since today morning
He also Complains of pedal edema grade 2
No history of chest pain, palpitation, burning micturition, shortness of breath, orthopnoea
HISTORY OF PAST ILLNESS:
Not a known case of HTN, CAD, Asthma, TB, Epilepsy, Thyroid disorders.
No history of surgeries and blood transfusions in the past.
PERSONAL HISTORY -
He has been consuming alcohol for the past 20 years 150 ml daily
FAMILY HISTORY -
No history of DM, hypertension, CVA, CAD, Asthma, Thyroid disorders in the family.
GENERAL EXAMINATION -
Patient is conscious, coherent, co-operative.
There is icterus and pedal edema.
No pallor, cyanosis, clubbing, koilonychia, lymphadenopathy.
VITALS -
Temperature- Afebrile
Pulse rate- 92 bpm
Respiratory Rate- 24 cpm
BP-100/70 mmHg
SPO2 at room air- 95%
GRBS 76 mg/dl
SYSTEMIC EXAMINATION -
CARDIOVASCULAR SYSTEM:
Inspection:
Chest wall is bilaterally symmetrical.
No precordial bulge
No visible pulsations, engorged veins, scars, sinuses
Palpation:
JVP: normal
Apex beat: felt in the left 5th intercostal space in the mid clavicular line.
Auscutation:
S1, S2 heard
Ejection systolic murmur heard in all areas (aortic, pulmonary, tricuspid and mitral areas) radiating to carotids.
RESPIRATORY SYSTEM-
Position of trachea: central
Bilateral air entry +
Normal vesicular breath sounds - heard
No added sounds.
PER ABDOMEN:
Abdomen is distended, soft and non tender.
Bowel sounds heard.
No palpable mass or free fluid
CENTRAL NERVOUS SYSTEM:
Patient is Conscious
Speech: normal
No signs of Meningeal irritation
Motor & sensory system: normal
Reflexes: present
Cranial nerves: intact
INVESTIGATIONS -
28-06-2021:
Provisional Diagnosis:
Infective endocarditis?
Hepatic encephalopathy?
29-06-2021:
30-06-2021:
Hemogram:
RFT:
Urine Sodium:
Urinary Potassium:
Urinary chloride:
Urine Protein: Creatinine ratio:
Coagulation profile:
PT - 15 sec
INR - 1.1
APTT - 31 sec
2D ECHO:
01-07-2021:
CBP:
RFT:
LFT:
02-06-2021:
RFT:
FINAL DIAGNOSIS:
INFECTIVE ENDOCARDITIS
WITH AV VEGETATIONS WITH MODERATE AS SEVERE AR
WITH AKI
WITH ?UREMIC ENCEPHALOPATHY ? SEPTIC ENCEPHALOPATHY
WITH ULCER OVER SOLE OF RIGHT LEG
WITH HYPOALBUMINEMIA ? ALCOHOLIC LIVER DISEASE
WITH ACUTE MULTIPLE INFARCTS IN BILATERAL CEREBRAL AND CEREBELLAR HEMISPHERES
Treatment given:
Day 1:
1. Inj. Monocef 1gm IV/BD
2. Inj. Vancomycin 500mg IV/BD in 100ml NS over 1hr
3. Procto clysis enema
4. Inj. Pan 40 mg Iv/OD
5. Inj. Thiamine 200mg in 100ml NS /BD
6. Inj. HAI 6U S/C TID
Day 2&3:
Same treatment followed
Day 4:
Same treatment followed except Inj. Monocef.
Inj. Augmentin 1.2 gm IV/TID
Tab. Ecospirn 150mg PO/HS/SOS
Tab. Clopidogrel 75mg PO/HS/SOS
Tab. Atorvas 20mg PO/HS/OD added.
Comments
Post a Comment