Medicine intern
Hello everyone.. I am an intern in Medicine and one of the important terms of getting the internship completion is to complete my log book with my daily log of what I learn during the course of my duties from my cases, the procedures that I do as well as the theory questions and discussion that I engage in.
Case report
He has slurring of speech since 3 days and weaknesses of right lower limb since 4 days.
while passing stools all of a sudden unable to getup weakness of rt lower limb 4 days back.
h/o involuntary micturition
no involuntary movements.
no drooling of saliva
no loss of consciousness
no deviation of mouth
no chest pain ,sob, palpitations,fever,cough
PAST HISTORY
hypertension since 3 years (2017) used medication for 1.1/2 year
no h/o DM ,CAD, epilepsy
? CVA 2yrs back right sided hemiparesis was diagnosed as hypertension also
hypertension medication &CVA stopped since 6 months
General examination:
Pallor absent
Icterus absent
- No cyanosis clubbing lymphademopathy,Edema
Afebrile
Bp 170/80 mm hg
Pr 82 bpm
spo2 99%
Cvs s1 s2 hears no murmurs
Rs bae + nvbs hears
P/a soft, non tender
Cns conscious
speech-comphrension present
no neck stiffness
no kernings sign
cranial nerves intact.
motor system -
tone. rt. lt
u/l. Increased N
l/l. Decreased N
power rt. lt
u/l. 4/5. 4/5
l/l. 0/5. 4/5
sensory system intact
reflexes. rt. lt
biceps. 3+. 2+
triceps. 3+. 2+
supinator. 2+. 1+
knee 1+. 2+
ankle. --. --
plantar-mute
INVESTIGATIONS
5/5/202O
HEMOGRAM :
Hb: 11.1 g/dl
WBC: 9500 cells / cumm
RBC : 3.88 million/ cumm
platelets: 2.06 lacks/cumm
Smear : normocytic normochromic
LFT.:Total bilirubin 0.62 mg / dl
Direct bilirubin 0.17 mg /dl
AST 120 IU / lit
ALT 14 IU /lit
Total protein 6.5 gm /dl
Albumin 4 gm /dl
Alkaline phosphatase 175 IU/lit
RFT
Urea : 65 mg /dl
Creatinine: 1.8 mg / dl
Calcium 10.5 mg/dl
potassium 3.2 meq/lit
RBS 147mg/dl
CUE :
Albumin :trace
2-3 pus cells
2-3 epithelial cells
Diagnosis: Right sided lower limb monoparesis with acute infarct in frontal lobe and chronic infarct in cerebellum and pons with uncontrolled hypertension
Treatment
T.ASPIRIN 75mg OD
T.ATORVAS 20 mg H/S
T.PAN 40mg OD
T. Amlodipine 10 mg OD
Monitor BP,PR,RR
Strict I/O charting
Procedure..
I have done an ascitic tapping in ckd ward
It was very fantastic experience the Ascitic fluid is haemorrhagic,I was very excited to know the reason I thought it might be malignancy but I could not find the reason because he left against medical advice
Theory topic-Hypertrophic cardiomyopathy
HCM is most commonly inherited from a person's parents.It is often due to mutations in certain genes involved with making heart muscle proteins.Other causes may include Fabry disease, Friedreich's ataxia, and certain medications such as tacrolimus.It is a type of cardiomyopathy, a group of diseases that primarily affects the heart muscle.
Diagnosis
electrocardiogram, echocardiogram, and stress testing.Genetic testing may also be done.
Treatment
betablockers, diuretics,or disopyramide.
A implantable cardiac defibrillator may be recommended in those with certain types of irregular heartbeat.
Surgery
septal myectomy or heart transplant, may be done in those who do not improve with other measures.
Thanks for sharing.
ReplyDeleteWhat is the age and gender of your patient?
Please share his clinical images and MRI images.
Why does he have azotemia and raised AST?
One way to follow up the ascitic patient is to phone him up and find out. You will find his number in the file.
Your theory shared appears to be a text book copy paste although I am not sure but from now on please put in quotes what ever you copy paste and always cite the reference. Avoid quoting more than one or two lines.
The internship completion is awarded not if the candidate writes something in the log book but by gauging the amount of learning accrued by the candidate as reflected in the log book.
Keep your log book comment box open and answer in your log book comment box and Mark as edit whatever whenever you edit your log book so that there is an audit trail.
Finally very well done Vaishnavi. Don't worry about my critical appraisal comments above as they are necessary for learning.
You are one of our best interns and I'm sure you will be able to demonstrate more medicine learning over the next ten days through your log book. 👍
A 60 yr old male patient sir
DeleteAzotemia was due to dehydration in this patient.Mri image in link given below
https://photos.app.goo.gl/UhZawdx5HzYpdHT19.
Thankyou sir