Internship Medicine Posting

intern log
    
    Hello everyone, I’m a medical intern and recently started my medicine  posting . This blog is to share my experience and cases i came across during this period.

CASE
        A 75 year old male patient came with the chief complaint of pedal edema and decreased urine output since 4 days.

HOPI:

Patient was apparently asymptomatic 4 days back , then developed bilateral pedal edema , pitting type, extending upto knees .

 He had decreased urine output associated with burning micturition ( on and off) . 

History of fever associated with chills and rigor 2 days back which subsided on medication.

No history of chest pain , palpitations , shortness of breath on exertion , jaundice , loss of appetite , fatigability.
No history of hesitancy , frequency or urgency of micturition. 

PAST HISTORY :

History  of similar complaints  4 months back for which he got treated by local doctor. 
 
Known case of CKD 

Known case of hypertension since 20 years and on regular medication . ( details not mentioned)

History of osteoarthritis since 10 years and uses diclofenac and ultracet( chronic nsaid abuse) 

No history of diabetes mellitus, asthma , epilepsy , CAD,CVA.

PERSONAL HISTORY:
  
Diet-mixed
Appetite-normal 
Sleep-adequate 
Bowel and bladder movements-regular 
Addictions- chronic smoker since 10yrs(4 beedies per day)
                   Occasional alcoholic (once in a year)

FAMILY HISTORY:
   
     Not significant

General examination:

         Patient is conscious ,coherent ,cooperative , moderatly built and moderatly nourished. 
Pallor present . No icterus , cyanosis, clubbing, koilonychia, lymphadenopathy . 
Bilateral pedal edema present

VITALS: 
              BP: 110/80 mmHg
               Temperature: afebrile
                Pulse : 86 bpm
                RR: 14 cpm
                SpO2 : 99%
                GRBS  : 118mg/dl

 Ecchymosis seen on upper part of forearm flexor aspect (right and left)
 
SYSTEMIC EXAMINATION :

CVS: S1, S2 heard .
          No thrills and murmurs.
          No raised JVP

 CNS: Higher mental functions: intact
           Cranial nerves: intact
           Sensory system : Normal 
            Motor system : Normal
             No cerebellar signs
             No signs of meningeal irritation

Respiratory system: bilateral air entry present 
                                 Normal vesicular breath sounds
                                  No added sounds

Abdomen: 
                 Inspection: scaphoid abdomen
                                    Epigastric pulsations seen
                                     No dilated veins and scars

                   Palpation: No organomegaly

                   Percussion:Dull note around umblicus
                   
                   Auscultaion: Bowel sounds heard

INVESTIGATIONS :



 

PROVISIONAL DIAGNOSIS :
CKD
Anaemia with thrombocytopenia
Chronic thrombus in intrahepatic part of IVC
 
TREATMENT :

Propped up position
Salt restriction
Fluid restriction
Tab. Lasix 40 mg/BD
Tab.PAN 40 mg / OD
Inj.Optineuron in 100 ml NS/IV/OD
Tab.Monocef/1 g/IV/BD
Strict diabetic diet
2egg whites per day
Atarax antiitch lotion
  
ADVICE AT DISCHARGE :
 
Follow up on saturday with hemogram, fasting and post lunch blood sugar and USG



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