INTERNSHIP ASSESSMENT ROLL NO:65

INTERNSHIP ASSESSMENT:

Posted in department of GENERAL MEDICINE from 12/12/22 to 11/2/23.

UNIT duties—-First 15 days (12/12/22-26/12/22)

  Last 16 days (27/1/23-11/2/23)

I would check the vitals of my patients and update SOAP notes Daily morning  and used to attend morning rounds  

Have taken samples and took the patients for required investigations 

Here are the blogs that I have done during my internship duties 

https://sannithreddykasala.blogspot.com/2023/02/a-case-of-15-yr-old-male.html

https://sannithreddykasala.blogspot.com/2023/02/a-case-of-85-year-old-female.html

https://sannithreddykasala.blogspot.com/2023/02/a-case-of-70-year-old-frmale.html

https://sannithreddykasala.blogspot.com/2023/01/a-case-of-36-year-old.html

https://sannithreddykasala.blogspot.com/2022/12/a-case-of-55-year-old.html

https://sannithreddykasala.blogspot.com/2022/12/a-case-of-60-year-old.html

https://sannithreddykasala.blogspot.com/2022/12/case-of-68-year-old-female.html

During OP DAY

I took the basic history of the patients and wrote the investigation required under the guidance of PG 

I have checked vitals of every patient 

Examined for reflexes, postural hypotension, Romberg’s sign

Have learnt basic management protocol few common conditions like headaches, fever, chestpain

NEPHROLOGY DUTY:

Monitored Blood Pressures of the patients during dialysis and in the CKD ward.

 while I was monitoring vitals , a patient had the Blood pressure-200/100 at 2:00AM.I've informed Dr.sailesh sir and he told to give Lasix and Nicardia,I got to know the role of lasix in CKD patients in clinical practice . 

I encountered another patient with SOB at 2 am then I put him on nebulization with salbutamol and ipratropium bromide and checked it's bp it's was 180/110 then we NICARDIA 10 mg after nebulization his sob reduced and patient felt releif and next day morning dialysis was done 

During ICU duty:

Monitored vitals of ICU and AMC patients.

Learnt drawing of ABG samples.

Inserted RYLES tube.

Done FOLEYS catheterisation .

Placed IV canula.

Assisted in Intubation with Dr Bharath and Dr shailesh sir 

I've Learnt the role of atracurium in patients with high Respiratory Rate. 

 learned to connect the oxygen mask and the no: of litres of water to be adjusted based on requirement and CPAP. 

WARD DUTY:

Monitored Bp for the patients with hypertensive urgency and made the chart of blood pressure recordings

Have attended the rounds.

Got SOAP notes updated of ward patients.

DURING PSYCHIATRY

Learned about importance of history taking and how history can guide us to probable diagnosis

vitals monitoring done for OP patients

Case related experience

1) Alcohol dependance- I've learnt the role of Loraz in alcohol withdrwal(1unit=30ml alcohol and we substitute 1 tablet of loraz for that) ,learnt the role of Baclofen in decreasing the cravings. Since thiamine is deficient in the we substitute that. I saw a patient who came early in morning with alcohol withdrawal tremors and he came drunk and want medication to stop drinking alcohol 

2) Schizophrenia- I saw a 60 year male having delusion of infidelity, persecution, visual hallucinations. He was given Risperidone and Trihexyphenidyl(for side effect of Risperidone). 

3) I've learnt how aggression(target oriented) is different from irritability(Generalized) for a person. 

4) panic attack- Loraz is given for the patient. 

5) I've learnt how we treat a patient with anger(uncontrolled anger, immediate- Haloperidol. Moderate anger- sodium valproate, mild anger -Loraz) 

Learnt about audit score - a parameter used in evaluating alcohol dependence

A CASE OF 15 YR OLD MALE

 Name: K.Sannith Reddy

Roll no. 65

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case : 

CHEIF COMPLAINTS: 

15 year old male student resident of Nalgonda complains of pain abdomen since yesterday

Vomitings Since Yesterday.

HOPI: 

Patient was apparently asymptomatic until 2 days ago then he had sudden onset of epigastric pain since yesterday morning non-radiating.

5 Episodes of vomitings since yesterday morning

first episode after one hour of lunch, food as content

Vomitings are green in colour bilious ,projectile 

Second episode is after 15 mins of drinking milk

Third episode after 20 mins of drinking Pulpy orange.

fourth episode after having grapes, last episode yesterday evening

No c/o Fever, Headache; Giddiness

NO c/o chest pain,sweating, palpitations,orthopnea,pnd,cough,sob 

NO c/o burning micturition,loose stools,nausea

No h/o DM,HTN,TB,ASTHMA,CVA,CAD

PERSONAL HISTORY

Diet mixed 

appetite normal 

sleep adequate 

no addictions 

bladder and bowel movements regular 

NO SIGNIFICANT FAMILY HISTORY

GENERAL EXAMINATION: 

Pt is c/c/c 

NO pallor,icterus,cyanosis,clubbing, lymphadenopathy, edema

vitals: 

BP-110/70mm hg 

pr- 75bpm

RR 17cpm 

Spo2 -98% ra

grbs 125mg/dl

SYSTEMIC EXAMINATION: 

CVS S1,S2 heard ,no murmurs 

RS- BAE + ,NVBS

P/A soft,nontender 

CNS: NFND 

INVESTIGATIONS: 

DIAGNOSIS: 

?ACUTE PANCREATITIS

TREATMENT: 

NBM Till further orders 

IV FLUIDS NS and DNS @100 ML /HR IV 

INJ TRAMADOL 1 AMP IN 100 ML NS IV TID 

INJ ZOFER 4MG IV STAT (NEXT SOS)

A CASE OF 85 YEAR OLD FEMALE

 Name: K.Sannith Reddy

Roll no. 65

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case : 

CHEIF COMPLAINTS : 

85 year old female came to the causalty with c/o shortness of breath and chest discormfort since 1 week 

HOPI: 

pt was apparently asymptomatic 27 years ago, had expiry of his husband (reason: attenders are saying because of old age, huaband was died).

20 years back, patient developed fever with Generalized weakness along with neck pain, where she was diagnosed with Diabetes and Hypertension and started on Medication.

She is a vegetarian and has no addictions. She stays along with her son, who has kirana shop, and her daily routine was she used to stay at home, not used to go outside and do Pooja, have food and watches television.

15 days back, patient developed sudden onset shortness of breath, 3 hours after having dinner, along with chest discomfort and sob aggravated on lying down position,along with cough.The attenders called RMP, but due to unavailability of vehicles, the patient was at home till 5am.At around 5 am in the morning, patient was taken to the area hospital, ECG was taken, told that it was heart stroke,where where she was given a injection (taking all the consents ??Thrombolysis) and she was taken

to the private hospital in warangal.

The treating doctor performed coronary angiography and advised for conservative management.

But upon request / force by attenders, PTCA was done to LAD and discharged after 3 days with

medication.

For 1 week, patient was fine and after that she again developed sudden onset shortness of breath,

where she was taken to the same hospital and conservative management was done, but due to

some issues, the attenders left the hospital and came here for further evaluation.

PAST HISTORY : 

K/C/O HTN SINCE 20 YEARS ON regular medication on metoprolol 25 mg 

K/C/O DM SINCE 20 YEARS on regular medication metformin 500 mg 

HISTORY OF CAD on medication ecosprin 150mg ,atorvas 40 ,clopidogrel 75 

PERSONAL HISTORY: 

Diet - mixed

Appetite- normal

Bowel and bladder movements regular

sleep- adequate

no addictions 

SURGICAL HISTORY: 

PTCA FOR LAD DONE ON 21/01/23

NO SIGNIFICANT FAMILY HISTORY 

GENERAL EXAMINATION: 

Pt is c/c/c 

NO icterus,cyanosis,clubbing,lymphadenopathy,edema

Pallor present 

vitals: 

BP-90/50mm hg 

pr- 108bpm

RR 20cpm 

Spo2 -100 on6lit o2 

grbs 216mg/dl

SYSTEMIC EXAMINATION: 

CVS S1,S2 heard ,no murmurs 

RS- BAE + ,Crepts present in B/L infrascapular region 

P/A soft,nontender 

CNS: NFND 

INVESTIGATIONS: 

2d echo: 

ECG: on 5/2/23

On4/2/23

On 3/1/23

Cxray: 

USG abdomen and pelvis: 

DIAGNOSIS: 

HEART FAILURE WITH REDUCED EJECTION FRACTION WITH S/P PTCA TO LAD 15 DAYS BACK 

CAG: TRIPLE VESSEL DISEASE WITH ANEMIA OF CHRONIC DISEASE WITH AKI ON CKD? 

K/C/O HTN,DM SINCE 15 YEARS 

TREATMENT : 

INJ MONOCEF 1G IV BD 

INJ LASIX 40MG IV BD 

INJ HUMAN ACTRAPID INJECTION S/C ACC TO GRBS AFTER INFORMING 

T CLOPIDOGREL 75MG PO BD 

T ECOSPRIN 150 MG PO HS 

T ATOCOR 20 PO HS 

INTERMITTENT CPAP 

INJ NORAD 1 MCG /KG/MIN (4ML+46ML NS)@ 2ML/HR INCREASE /DECREASE TO MAINTAIN MAP>/= 65MMHG

A CASE OF 70 YEAR OLD FEMALE

 Name: K.Sannith Reddy

Roll no. 65

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case :

COMPLAINTS AND DURATION

A 70year female house wife by occupation brought to the Casuality

c/o fever since 4 days

slurring of Speech since 4 days.

SOB since 4 days

B/L pedal edema since 4days 

Left upper limb and lower limb weakness since 10years 

HISTORY OF PRESENT ILLNESS :

Patent was apparantly asymptomatic 4 days back then she developed fever low grade associated with chills and rigor Assosiated with shortness of breath grade 2 & associated with slurring of Speech and b/l pedal edema pitting type

weakness of left upper limb and lower limb from 10years

For fever they took treatment at local Rmp

HISTORY OF PAST ILLNESS

Is k/c/o HTN since 10 years on telma 40mg 

IS N/K/C/O DM/ASTHMA/CAD/EPILEPSY 

underwent craniotomy 10 years back at gandhi hospital for cerebral hemorrhage where she was diagnosed to have hypertension and started on medication

H/o NSAID Abuse

PERSONAL HISTORY: 

Diet - mixed

Appetite- normal

Bowel and bladder movements regular

sleep- adequate

Addictions: 

Alcohol (toddy) consumption occasional once in 6 months

DRUG HISTORY : 

On telma 40 medication since 10 years for hypertension.

SURGICAL HISTORY: 

Underwent craniotomy for cerebral hemorrhage 10 years back in Gandhi hospital 

From then pt had weakness in left upperlimb and lower limb 

GENERAL EXAMINATION: 

Pt is c/c/c 

No ,icterus,cyanosis, clubbing, lymphadenopathy

Pallor present

edema present (pitting type)

vitals: 

temp - 99°F

pr: 102bpm,bp: 100/80 mm hg 

rr:16cpm spo2 95% at ra 

grbs- 160mg%

SYSYTEMIC EXAMINATION: 

CVS: S1, S2 heard no murmurs

RS: BAE presnt ,NVBS heard

P/A: distended ,non tender 

CNS:

pupils -B/L NSRL              

Tone:

Normal in both upper limb and lower limb on right side but decreased on left side 

POWER : 

Right side: UL 4/5,LL 4/5

Left side: UL 3/5 ,LL 3/5 

REFLEXES: 

                  B T. S. K. A. PLANTAR 

RIG       ++. ++. +. ++. +.  

LEFT.     ++. ++ +. ++. +.  

INVESTIGATIONS: 

ECG: 

29/1/23

28/1/23

NCCT KUB: 

2D ECHO: 

USG ABDOMEN AND PELVIS: 

XRAY CHEST: 

ABG: 

28/1/23

29/1/23

30/1/23: 

31/1/23: 

BLOOD C/S : E.COLI WAS ISOLATED

URINE C/S : NO GROWTH FOUND 

PROVISIONAL DIAGNOSIS: 

SEPSIS WITH AKI (RESOLVING)

?EARLY EMPHYSEMATOUS PYELONEPHRITIS WITH RIGHT RENAL CALCULI WITHODERATE RIGHT HYDROURETERONEPHROSIS

K/C/O HTN since 10 years 

TREATMENT GIVEN: 

On28/1/23

) IVF RL and NS @100ml/hr 

2)INJ PIPTAZ 2:25 mg IV/TID

3)INJ NEOMOL 1GM IV IF TEMP > 100F

4)INJ PAN 40MG IV/OD

5)INJ ZOFER 4mg IV SOS

6)INJ OPTINEURON 1 AMP IN 100ml NS IV OD

7)T Dolo 650MG PO sos

8)T NODOSIS 500MG PO BD 

9)T ECOSPRIN- AV 75/10 mg PO OD 

10) T NICARDIA 10MG PO SOS

On 1/2/23

S

chills present at night but no fever spikes 

O 

Pt is c/c/c 

Temp 98.6°F°F 

pr -90bpm 

Bp: 100/70mmHg

spo2 98% on ra 

grbs- 98mg/dl

i/o 2300/1150

CVS : s1,s2 herad 

RS: BAE + 

CNS: NFND 

p/A : soft ,NT

Hb: 12.1---10.3---9.7---10---9.3

TC- 25.9k----17.1k---10.5k---11.6k---23.4k(raised)

RBC -4.23---3.64---3.4---3.52---3.2

PLT- 1.2L---65000---1L---1.43L---1.94L 

SERUM ELECTROLYTES: 

Na+ 137---138---136---137---136

k+. 5.6---4.5---4.9---5.1---5.3

Cl-114---102---104---104---10

A

SEPSIS WITH AKI (RESOLVING)

?EARLY EMPHYSEMATOUS PYELONEPHRITIS WITH RIGHT RENAL CALCULI WITHODERATE RIGHT HYDROURETERONEPHROSIS

K/C/O HTN since 10 years 

P

1) IVF 2unit NS @75ml/hr 

2)INJ PIPTAZ 2:25 mg IV/QID STOPPED AFTER GIVING FOR FOUR DAYS AS COUNTS ARE INCREASING AND STARTED ON INJ MEROPENEM 

3)INJ NEOMOL 1GM IV IF TEMP > 100F

4)INJ PAN 40MG IV/OD

5)INJ ZOFER 4mg IV SOS

6)INJ OPTINEURON 1 AMP IN 100ml NS IV OD

7)T Dolo 650MG PO sos

8)T NODOSIS 500MG PO BD 

9)T ECOSPRIN- AV 75/10 mg PO OD 

10)T CLINIDIPINE 10MG PO/BD 

11)SYP CREMAFIN 15ML PO/HS 

12)OINT THROMBOPHOBE FOR L/A 

13)PROTEIN XPOWDER 1 SCOOP IN 100ml milk PO/TID

14) NEBULIZATION WITH DUOLIN 8TH HOURLY

15)MONITOR VITALS 2ND HOURLY

16) STRICT I/O CHARTING 

WAITING FOR BLOOD C/S REPORTS

A CASE OF 36 YEAR OLD MALE

 Name: K.Sannith Reddy

Roll no. 65

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case :

cheif complaints : 

36 year old male Barber by occupation 

resident of Saidabad- complains of alcohol.

addiction came for deaddiction.

After coming, BP was noted 180 / 110mming PR:91bpm.

k/c/o HTN since 6 months and missed morning dose of Antihypertensive

c/o burning pain the in epigastric region since1 month

c/o decreased appetite since one year 

No H/o Fever; cough; cold

No H/o chest pain, palpitations; Sweating; SOB; orthopnea; PND

No H/ loose stools; Nausea, vomiting.

No H/o Burning micturition.

 HISTORY OF PAST ILLNESS

k/c/o HTN since 6 months 

N/k/c/o DM/THYROID/EPILEPSY/CAD/TB/ASTHMA/CVA 

PERSONAL HISTORY: 

Barber by occupation 

Diet - mixed

Appetite- decreased 

Bowel and bladder movements regular

sleep- disturbed

Addictions: 

Alcohol consumption since 5 years 1/2 bottle per day 

cigarette smoking since 9 years 3 per day 

ALCOHOLIC HISTORY: 

Patient didn't used to consume alcohol 5 years ago, then started drinking alcohol in the form of beer along with his friends. He continued to drink with his friends on special occasions and events. He gradually shifted to whiskey after 2 years. Currently Consuring about 12-16 units/day(1/2 bottle per day). Patent reports strong urge to take alcohol Patient experiences sleep disturbances and tremors when alcohol is stopped 

 He started neglecting his job and health and is interested in obtaining in alcohol instead. Continues to consume alcohol despite knowing its harmful consequences. About 2 months ago pt was admitted in Malakpet Deaddition center for about to days, but couldn't stay long without alcohol and felt the medication prescribed did not help him. 

DRUG HISTORY: 

On clinidipine 10mg and Telma H for hypertension since 6 months

 

FAMILY HISTORY: 

Mother and father are known case of diabetes 

Mother is a known case of hypertension too 

Father was a social drinker died due to cardiac arrest 

GENERAL EXAMINATION: 

Pt is c/c/c 

No pallor,icterus,cyanosis, clubbing, lymphadenopathy,edema 

vitals: 

temp - afebrile 

pr: 91bpm,bp: 180/120 mm hg 

rr:20 cpm spo2 98% at ra 

grbs- 90mg%

SYSYTEMIC EXAMINATION: 

CVS: S1, S2 heard no murmurs 

RS: BAE presnt ,NVBS heard 

P/A: soft,non tender 

CNS: No focal neurological deficit 

alcoholic withdrawal tremors present 

PROVISIONAL DIAGNOSIS: 

ALCOHOL DEPENDENCE, K/C/O HTN SINCE 6MONTHS , HYPERTENSIVE URGENCY 

INVESTIGATIONS: 

ECG: Showing LVH

TREATMENT GIVEN: 

T. TELMA CT 80/12.5 MG PO OD

T. NICARDIA RETARD 10MG PO TID

T. THIAMINE 200MG PO TID

T. BACLOFEN XL 20MG PO OD

TAB LORAZEPAM 2mg  2 tab at night for 3 days 

A CASE OF 55 YEAR OLD

 Name: K.Sannith Reddy

Roll no. 65

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case :

Cheif complaints: 

55 year old male cattle rearer by occupation was brought to the casualty with complaints of Inability to move left sided upper and lower limb since 6 days

Inability to speak since morning

History of presenting illness: 

Patient was apparently asymptomatic 6 days back then he developed weakness of left upper and lowerlimb after waking up from sleep

For which he was taken to hospital and diagnosed to have multiple infarcts in frontotemporal  areas was treated conservatively

During the stay patient developed an episode of seizure

Lasted for 10 min ?focal seizure   , post ictal confusion for 15min 

Later patient was discharged 

Yesterday night patient had an episode of seizure , focal tonic clonic involving left upperlimb for 5minutes , gained consciousness after 10 minutes 

Following which  patient was unable to speak patient is conscious and devoloped weakness in left upper limb and lower limb also devoloped  urinary incontinence not a/w vomitings

Pasthistory: 

- K/C/O Dm since 5 years (under irregular medication)

K/c/o HTN 

N/k/c/o asthma ,CAD , TB

Had left index finger amputated 

PERSONAL H/O:

APPETITE NORMAL

DIET MIXED

SLEEP: ADEQUATE 

BOWEL MOVEMENTS REGULAR AND BLADDER: URINARY INCONTINENCE PRESENT 

NO KNOWN ALLERGIES

FAMILY HISTORY: NO RELEVANT FAMILY HISTORY.

GENERAL EXAMINATION: 

PT is c/c/c 

No palor icterus cyanosis clubbing lymphadenopathy,edema 

Vitals @admission: 

Temp afebrile

Pr 88bpm

Bp 110/70

Spo2 98%

SYSTEMIC EXAMINATION: 

cvs :JVP not raised, s1 s2 heard 

RS: BAE + NVBS heard 

p/A soft non tender 

CNS : 

HMF present ,oriented to time ,place and person 

Tone : RT LT

UL     N. Hyper

LL      N. Hyper 

POWER 

UL      5/5. 2/5

LL       5/5 2/5 

REFLEXES: B. T. S. K. A. Plantar

RT.            ++. ++. +. ++. + extension  

LT.            ++. ++. +. ++. +. extension

INVESTIGATION: 

PROVISIONAL DIAGNOSIS: 

1)CVA WITH ACUTE INFARCT OF RIGHT TEMPORAL AND OCCIPITAL LOBE AND B/L FRONTAL LOBE ( with intraparenchymal hemorrhage)

2)DIABETIC KETOSIS(resolving) SECONDARY TO NON COMPLIANCE 

3)WITH TYPE 2 DM SINCE 5YEARS 

Treatment: 

On 24/12/22 

INJ HAI s/c ACC TO GRBS

INJ MANNITOL 300 ML iv TID 

INJ LEVIPILL500 MG IV BD 

TAB ATORVAS 10 MG PO/HS 

On 25/12/22 AMC DAY2 

S

no fever spikes 

stools not passed 

O 

pt is c/c/c 

temp : afebrile

pr 68bpm 

bp: 110/70mm hg 

spo2 98% on ra 

grbs: 163 mg/dl

GRBS AT 

10pm- 160

12am-185

2am-152

4am-149

6am-168

8am-163(12 units HAI given)

cvs :JVP not raised, s1 s2 heard 

RS: BAE + NVBS heard 

p/A soft non tender 

CNS : 

HMF present ,oriented to time ,place and person 

Tone : RT LT

UL     N. Hyper

LL      N. Hyper 

POWER 

UL      5/5. 3/5

LL       5/5 4/5 

REFLEXES: B. T. S. K. A. Plantar

RT.           ++. ++. +. ++. + extension   

LT           ++. ++. +. ++. +. extension

A 

1)CVA WITH ACUTE INFARCT OF RIGHT TEMPORAL AND OCCIPITAL LOBE AND B/L FRONTAL LOBE ( with intraparenchymal hemorrhage)

2)DIABETIC KETOSIS(resolving) SECONDARY TO NON COMPLIANCE 

3)WITH TYPE 2 DM SINCE 5YEARS 

 

RX 

 INJ HAI s/c ACC TO GRBS

INJ MANNITOL 300 ML iv TID 

INJ LEVIPILL500 MG IV BD 

TAB ATORVAS 10 MG PO/HS

A CASE OF 60 YEAR OLD

 Name: K. Sannith Reddy

Roll no. 65

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case :

Cheif complaints

A 60 year old male was brought to casualty with altered sensorium since yesterday night

History of presenting illness: 

Patient was apparently asymptomatic 10 years back then he developed similar kind of symptom and was diagnosed with type 2 DM and started on OHA's later after few years (?3y) patient was shifted to Insulin (HAI twice daily)

After 4yrs Patient developed giddiness and while working patients had fall ,fracture Rt UL and Rt LL And diagnosed with HTN-( on anti hypertensive medication- Telma50 -ch12.5,METXL 40 )

2 yrs back patient developed similar episodes of altered sensorium and was having Hyperglycemia he went to pvt hospital at pvt hospital then was diagnosed to have? DKA → given Insulin and treated.

10 days back pt developed swelling of lower limb , and ulceration on right toe and Plantar aspect of foot for which he went to put practictiner and diagnosed to have diabetic foot and was treated with regular dressings and antibiotics.

From 4 days pt had nausea and vomitings (2 episodes per day) with food intake ,non blood tinged 

vomitings not associated with fever ,cold ,cough,Pain abdomen, loose stools 

Past history: 

N/K/C/O asthma, CAD, Epilepsy 

PERSONAL HISTORY 

DIET MIXED 

SLEEP ADEQUATE 

BOWEL AND BLADDER MOVEMENTS REGULAR 

ALCOHOL OCCASIONAL 

NO SIGNIFICANT FAMILY HISTORY.

GENERAL EXAMINATION : 

PT IS drowsy 

NO PALOR, ICTERUS ,CYANOSIS,CLUBBING,EDEMA, LYMPHADENOPATHY 

Vitals @ admission 

Temp 98.6 F 

Pr 86bpm

Bp 130/80mm hg 

Spo2 97%

GRBS 123mg/dl

SYSTEMIC EXAMINATION: 

CVS - S1,S2 +

RS - BAE + , NVBS

CNS - Pt is drowsy , arousable to deep pains

speech slurred 

No meningial signs 

GCS E3 V2 M5

Tone : RT   LT

UL.    N         N

LT.       N.      N

REFLEXES: B. T.   S. K.  A.  Plantar

RT.              ++. ++. +. ++. +  flexion 

LT.                +. +  . +.   +   + flexion 

INVESTIGATION:

CHEST XRAY :

         

USG ABDOMEN
       

MRI BRAIN: 

PROVISIONAL DIAGNOSIS: 

)Altered sensorium secondary to hypotonic hyponatremia euvolemic ? SIADH

2)with small hemorraghic contusion of frontal lobe

3)With HTN since 4 years 

4)with type2 DM 

TREATMENT: 

Given on 24/12/22

Iv fluids 3% Nacl @ 15ml/hr

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd hrly

Inj.kcl 20 Meq in 100 ml NS over 2 hrs /IV / STAT

Inj Zofer 4 mg /Iv/Tid

Inj Pan 40 mg / Iv / Od

Inj. Hai sc tid acc to sliding scale

Syp. potchlor 15ml/po/Tid

INVESTIGATION CHART

ICU DAY2 25/12/22

 

AGE : 60Y GENDER :M

S: 

No fever spikes

cough with sputum

O:

Pt is drowsy but arousable 

oriented to person but not time and place 

BP - 140/80 mm Hg

PR - 83 bpm

RR 21cpm

SPO2 - 98% @ RA

GRBS - 116 mg/dl

Temp - 98.4 F

CVS - S1,S2 +,Jvp not raised

RS - BAE + , NVBS

CNS - Pt is conscious but drowsy 

No meningial signs 

GCS E3 V4 M6

Tone : RT LT

UL N. N

LL N. N

REFLEXES: B. T. S. K. A. Plantar

RT. +. + . +. +. + flexion 

LT. +. +. + + + flexion 

A: 

1)Altered sensorium secondary to hypotonic hyponatremia euvolemic ? SIADH

2)with small hemorraghic contusion of frontal lobe

3)With HTN since 4 years 

4)with type2 DM 

P: 

Iv fluids 3% Nacl @ 15ml/hr( increase or decrease

 acc to serum electrolytes

RT feeds - 100 ml water 1 hrly 100 ml milk 2nd hrly

(D1)Inj monocef 1g iv bd 

Inj Zofer 4 mg /Iv sos

Inj Pan 40 mg / Iv / Od

Inj. Hai sc tid acc to sliding scale

(W/H)tab aldactone. 25 mg po bd 

tab nicardia @10 mg po bd 

coconut water through ryles tube 50ml bd 

Syp. potchlor 15ml/po/Tid

A CASE OF 65 YEAR OLD FEMALE

 Name: K.Sannith Reddy

Roll no. 65

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Cheif complaints: 

patient came to the General medicine Opd with clo Cough (dry) & SOB 2months ago 

HISTORY OF PRESENT ILLNESS

Patient was  apparently asymptomatic till 2months ago. Then she had Dry Cough with SOB for 2 days she went to RMP doctor and she was treated with medication ( unknown) then symptoms subsided 

she is farmer by occupation 2 months age while she is carrying Dry grass she had sudden onset of cough and sob started in the evening and present for two days; went to Rmp doctor and managed with medications (unknown) .

 

Cough is dry; Intermmitent not associated

with chest pain while coughing.

 Not associated with Fever,Headache. 

SOB (G-II) on lifting weights. Relieves after taking medications( unknown) 

not alw orthopnea, & PND, Palpitations,chest pain 

 HISTORY OF PAST ILLNESS

N/Klc/o HTN/DM/CAD/ Epilepsy/ TB /CVA

PERSONAL HISTORY 

DIET MIXED 

SLEEP ADEQUATE 

BOWEL AND BLADDER MOVEMENTS REGULAR 

ALCOHOL OCCASIONAL 

NO SIGNIFICANT FAMILY HISTORY.

GENERAL EXAMINATION : 

PT IS C/C/C WELL ORIENTED TO TIME ,PLACE AND PERSON 

vitals @ admission : 

BP: 150/90mm hg 

PR: 80BPM,REGULAR 

GRBS: 447MG/DL 

TEMP AFEBRILE  

NO PALOR,ICTERUS,CYANOSIS,CLUBBING,EDEMA, LYMPHADENOPATHY 

SYSTEMIC EXAMINATION: 

RS: BAE+ , NVBS HEARD ,

CREPTS ABSENT, NO WHEEZE,NO RHONCHI 

CVS S1,S2 HEARD ,NO MURMURS 

P/A SOFT ,NT 

CNS: NFND

INVESTIGATIONS: 

GRBS 

At the time of admission : 447mg/dl

22/12/22

8 am 122mg/dl 

10am 104mg/dl (6units HAI +6unitsNPH given)

10pm 205mg/dl

23/12/22

2am -160mg/dl

8 am 134mg/dl

Hemogram: 

HB: 12:4

PCV: 36.1

TC: 7200

NEU: 54

MCV: 86.6

MCH: 29.7

LYM: 36

MCHC-34.3

MON: 07

RDW-CV. 11.4

EOS: 03

RBC: 4.17

PLT 2.38 lakh

CUE : 

ALBUMIN TRACE 

SUGARS NIL

PUS CELLS 2-3 

Urine for ketones neagtive 

Fbs- 100mg/dl

Plbs- 152mg/dl

HbA1c 6.8

Chest xray: 

Showing mediastinal lymphnode 

ECG: 

Showing Normal sinus rythm .

2d echo: 

mitral valve : pml calcification, restricted.

RVSP:35MM HG , Ef 67%,IVC 0.9cm

+ Mild AR+/MR+,Trivial TR+ 

NO RWMA ,no AS/MS ,sclerotic Av

Good LV systolic function

Diastolic dysfunction+ NO PAH/PE

Provisional diagnosis: 

1)? Acute exacerbation of asthma 

2)? Allergic bronchitis

Treatment given : on 22/12/22

1) TAB MONTEK LC PO BD (1-X-1)

2) SYP GRYLLINCTUS 15ML PO BD

 3) TAB DOLO 650 MG PO SOS

4)6units HAI + 6 UNITS NPH 

Treatment given on 23/12/22

1) TAB MONTEK LC PO BD (1-X-1)

2) SYP GRYLLINCTUS 15ML PO sos

3) TAB DOLO 650 MG PO SOS

4) TAB GLIMI M1 PO OD at 8am BBF