Final practical examination-short case
FINAL PRACTICAL EXAMINATION-SHORT CASE
Feb 8,2022
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CHIEF COMPLAINTS:
A 50 year male patient farmer by occupation brought to casualty with h/o altered sensorium since 1 day
H/o fever since 4 days.
HISTORY OF PRESENTING ILLNESS -
Patient was apparently asymptomatic 4 days ago,then he developed fever which is high grade,No diurnal variation, associated with chills.
No h/o cough and GI symptoms.
Attenders tells h/o stoppage of oral hypoglycemic agents for 3days, h/o decreased intake of food as he has fever.
H/o altered sensorium since 1 day.
Irrelevant talk,not recognising attenders since this morning .
Able to move all four limbs,No h/o vomitings, head ache, seizures.
Took him to nalgonda hospital, TLC-13,000:POT-5.0:CREATININE:2.9
SHIFTED HERE FOR FURTHUR MANAGEMENT.
PAST HISTORY -
H/o TB 2YRS back used Anti Tubercular Therapy for 6 months.
Diagnosed as Type -2 Diabetes mellitus on Oral hypoglycemic agents 1 YR back.
No H/O Hypertension,asthma,Cerebro vascular accident
PERSONAL HISTORY :
DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR ,
BLADDER MOVEMENTS - REGULAR, ADDICTIONS-H/O SMOKING 30yrs ago(1 pack per day)-
ALCOHOL-REGULAR INTAKE OF 180ML SINCE 30YRS,STOPPED SINCE 2YRS AFTER DIAGNOSIS OF TB.
RECENTLY ALCOHOL INTAKE ON JAN 15,2022.
FAMILY HISTORY:
Non-significant.
TREATMENT HISTORY:
on oral hypoglycemic agents since 1 year
ON Anti Tubercular Therapy for 6 months
ON EXAMINATION -
PATIENT IS CONCIOUS , INCOHERENT, NON COOPERATIVE
NO ICTRUS
NO PALLOR
CLUBBING:present.
NO CYANOSIS , NO LYMPHADENOPATHY, NO EDEMA
VITALS -
TEMPERATURE - 97' F
PULSE RATE - 126BPM
BLOOD PRESSURE - 190/80 MM OF HG
RESPIRATORY RATE - 28
SPO2 - 97 % AT ROOM AIR
GRBS-HIGH.
SYSTEMIC EXAMINATION -
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS
DYSPNOEA PRESENT.
P/A - soft,non tenderness, no organomegaly
CNS: Pt is conscious, inorientation ,non cooperative
Motor system:unable to move right LL against gravity.
Tone - Rt Lt
U/L N N
L/L ?HYPO N
Reflexes:
Biceps,triceps,supinator,knee,ankle:can't be elicited.
B/L PLANTAR EXTENSION PRESENT.
O/E NECK STIFFNESS PRESENT,APPEARS TO BE ?SPONDYLOARTHROPATHY.
INVESTIGATIONS:
Serum creatinine:
ECG:
Complete urine examination:
Urine for ketone bodies:
Serum electrolytes:
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