Final Practical Examination

Final Practical Examination - SHORT Case

June 12, 2022

Hall Ticket No: 1701006188

Name: Vaishnavi Maguluri

SHORT CASE

Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs.

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Consent: An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.

A 45 year old male, station worker by profession presented with the,

CHIEF COMPLAINTS :

1. Shortness of breath on exertion since 2 months.

2. Tingling sensation of limbs since 2 months.

3. Dark colored stools 3 days back

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 20 years ago when he developed drooling of saliva, upward rolling of eyeballs, tonic clonic movements with involuntary movements.

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Taken to hospital, diagnosed as epilepsy - used medication.

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Later developed 2-3 episodes of seizures in 15 days.

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Seizure free period for 2 years - Tapered medication.

Patient is now complaining of shortness of breath since 2 months, present on exertion at work while loading and unloading parcels at railway station and tingling sensation of limbs since 2 months.
The patient also complains of intermittent fever since 2 months. Not associated with vomiting, headache, dizziness.
History of dark colored stools 3 days back - 2 episodes for 1 day.

PAST HISTORY:

Patient is a known case of epilepsy.
Patient is not a known case of Hypertension, Diabetes, Thyroid disorders, Tuberculosis, Asthma or any cardiac disorder.
No history of any antibiotic intake, blood transfusion or previous surgeries.

PERSONAL HISTORY:

His appetite is normal, he consumes a mixed diet, sleep is disturbed, bladder bowel movements normal and regular and complains of dark colored stools 3 days back.
He consumes 90-100ml alcohol everyday since 15 years. ( chronic alcoholic).
No history of smoking or betel nut chewing.
No known food or drug allergies.
Married

FAMILY HISTORY:

No similar complaints in the family members.
No chronic diseases in family.

GENERAL PHYSICAL EXAMINATION:

Patient was conscious, coherent, co-operative, slightly irritable and well oriented to time, place and person.
Moderately built and nourished.
Pallor present.
No signs of Icterus, Cyanosis, Clubbing of fingers or toes, Generalized Lymphadenopathy, Edema of feet.

Vitals:

Temperature - Afebrile

Respiratory Rate - 18 cpm

Pulse Rate : 98 bpm

Blood Pressure - 110/80 mm Hg

SpO2 - 98% at RA

GRBS - 108mg%

SYSTEMIC EXAMINATION:

CVS : S1, S2 heard.

Respiratory System : Bilateral air entry is present. Normal vesicular breath sounds are heard.

No wheeze or any adventitious sounds. Position of trachea central.

Central Nervous System : No abnormality detected.