PREFINAL PRACTICAL EXAM 1801006156

 PREFINAL PRACTICAL EXAM


45 year old Female, farmer by occupation came to medicine OPD with chief complaints of

  • Fever since 5 days
  • Loose stools 2 days back

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 5 days back   then she developed  low grade fever  which was insidious in onset and intermittent in nature associated with chills and rigor.


Loose stools 2 days back ,4 episodes liquid in consistency ;not associated with blood.

Weakness since 5 days.

History of  dry cough since 4 days.

No history of burning micturition.

No history of pain abdomen.

No history of intake of outside food.

No history of pain abdomen.

No history of vomiting.

No history of toddy drinking.

DAILY ROUTINE:-

Patient wakes up at 7 AM and does her household work  and have breakfast around 9 AM and goes to work at agriculture land for  3 hrs and comes back between 12-1 PM and have lunch at 2PM, takes rest for the day. Patient have dinner at around 8PM and goes to sleep at 9PM.She takes rice with curry or dal for three times.

PAST HISTORY:-

Not a known case of hypertension,DM,Asthma,Epilepsy,Thyroid disorder,tuberculosis.

Hysterectomy done 15 years back.


FAMILY HISTORY:-

No significant family history

PERSONAL HISTORY:-

Appetite :- decreased

Diet          :- Mixed 

Sleep        :-Inadequate

Bowel       :- Increased movements 

Addictions :- Occasional toddy drinker

                      Not a smoker

GENERAL EXAMINATION:-

Patient is conscious,coherent, and cooperative well oriented to time place and person moderately built and nourished 

Pallor - Absent

Icterus - Absent

Cyanosis -  Absent

Clubbing - Absent

Lymphadenopathy - Absent

Pedal edema - Absent








VITALS:-

Temperature - Afebrile

Pulse- 68bpm

Blood pressure - 110/80 mmhg

Respiratory rate - 21 cpm

SYSTEMIC EXAMINATION:-

CVS- 

Inspection:-

JVP not seen

Auscultation

S1 S2 heard

RESPIRATORY SYSTEM

chest is bilaterally symmetrical

bilateral airway entry present

trachea - Midline 

no scars

Percussion:-Resonant in nine quadrants

Auscultation- Normal vesicular breath sounds heard

ABDOMINAL EXAMINATION

INSPECTION 

abdomen is flat

Umbilicus is central 

No dilated veins

No scars and sinuses

PALPATION

All inspectory findings are confirmed 

No localised rise in temperature

No hepatomegaly 

No splenomegaly

AUSCULTATION

Bowel sounds are heard


CNS EXAMINATION

speech normal

no focal neurological deficits seen


Provisional diagnosis:-

Acute gastroenteritis 


INVESTIGATIONS

On 14/06/2023

Complete blood picture

hemoglobin - 12.0 gm/dl

total count - 5,900cells/cumm

neutrophils - 62%

lymphocytes - 31%

pcv - 34.6%

MCHC 34.7

MCV - 87.2

MCH - 30.2

Platelet count -2.66

blood group A+

interpretation- Normocytic normochromic blood picture


Random blood sugar - 99 mg/dl


Renal functional test

urea            35 mg/dl

creatinine 0.8mg/dl

uric acid    2.8 mg/dl

sodium    136mEq/L

Potassium -3.3 meq/l

chloride -106 mg/dl

COMPLETE URINE EXAMINATION:


Liver function test

Alkaline phosphate    199 mg/dl

total protein               7.0 gm/dl

albumin                       3.10gm/dl


ECG:-



TREATMENT
IV Normal saline
Tab.Dolo 650 mg PO/BD


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