33 year old male patient

33 year old male patient 


GM Blog: 33 year old male patient 


NOTE
This is an ongoing case and will be updated 
The reference link (if any) will be mentioned at the bottom.

Date of admission: 29-10-2022

CHIEF COMPLAINT: patient came to the opd with complaints of burning and painful micturition since 2 years.

C/o  Dyspareunia ( painful intercourse) since 2 years.
C/o  Bilateral Decreased hearing since 2 years
C/o indigestion and pain abdomen since 5 years

HISTORY OF PRESENT ILLNESS-

Patient was apparently asymptomatic 5 years back then he developed pain abdomen and epigastric burning sensation episodically for which he went to the local hospital 
The pain was located in the left flank and sometimes radiating to the whole abdomen.
Relieving factor - medication
Aggravating factor- non vegetarian food like chicken, mutton and fish
He had few episodes of vomiting during the indigestion. Vomitus mostly included food particles.
following which he developed papules in the leg which lead to blisters and hyperpigmentation of the skin of both the limbs. It is non tender.
Later he developed burning, painful micturition and inability to retract prepuce since 2 years.


PAST HISTORY:

Known case of Diabetes mellitus since 7 yrs 
Whitish ear discharge in both ears since childhood, progressive, non foul smelling for which he visited many hospitals and clinics. He underwent an ear surgeries in the year 2009 and 2015 .
He had no complaints of tinnitus and vertigo.
He met an accident 15 years back during which he injuried his left leg.
No history of coronary artery disease, epilepsy, asthma, kidney diseases , tuberculosis,  fits or any other chronic illness 

PERSONAL HISTORY:
Married 
Obese 
Diet: mixed. ( Non vegetarian)
Sleep- reduced 
Appetite - normal 
Bladder movement- painful and burning 
Bowel movements- normal 
Allergy- dust allergy 
Addiction- alcohol occasionally. ( Stopped since last 3 months ) 


FAMILY HISTORY:
Father and mother known case of diabetes mellitus

GENERAL EXAMINATION:
Patient is conscious, coherent, co-operative.
He is well oriented to time, place and person. 
Obese 
Pallor - absent 
icterus absent
No cyanosis
No clubbing
No edema 
No Lymphadenopathy  


Vitals 
Temperature: 98.6 F 
Pulse rate : 86 beats /min
Respiratory rate: 18/ min
Blood pressure: 110/ 70 mmHg 
Spo2-98%
Random blood sugar: 126 mg /dl

Systemic examination 

Cardiovascular system
S1, S2 heard
No murmurs 

Respiratory system

Wheeze and dyspnea absent 
Position of trachea: central
Breath sounds: Vesicular
Adventitious sound: absent 

Abdomen
Shape of abdomen: scaphoid
Non tender
No palpable mass
No free fluids
Spleen and liver not palpable

Central nervous system
Conscious
Speech: normal
Neck stiffness - no

ENT examination
Bilateral Decreased hearing 
































Investigations

















Gastroenterology 





Treatment: 

Comments

Post a Comment

Popular posts from this blog

39 year old male patient from West Bengal

Image
This is a case of a 39 year old bus driver who is a resident of West Bengal. CHIEF COMPLAINT : Abdominal distension since 2 months. Swelling in the leg since 2 months. Decreased appetite since 2 months. Decreased urine output since 1 month.   HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic 2 months ago then he developed abdominal distension which was insidious in onset and gradually progressive, associated with decreased appetite. Later he developed bilateral pedal edema extending upto the knees which is of pitting type. After a month his urine output got decreased still he continued his work as a bus driver. His relatives started noticing that his abdomen is getting distended and his appetite is decreased. They suggested him to see a doctor following which he took a homeopathic treatment in West Bengal But there was no improvement. He also took some ayurvedic medication but nothing seemed to work out. Then he came to our hospital with complaints of abdominal distension
Read more

OSCE and Learning points

Image
OSCE AND LEARNING POINTS PREFINAL PRACTICAL EXAMS NAME : VAGISHA RANI ROLL NO: 138 DATE: 4 December '23 Blog link: https://vagisharani.blogspot.com/2023/12/48-year-old-male-patient-from-west.html QUESTIONS  1) West haven criteria clinical grade for hepatic encephalopathy. 2) Wilson's disease and cirrhosis of liver  Wilsons diease is an inborn errors of copper metabolism characterised by increased total body copper. Etiology: Molecular defect within the copper transporting ATPase encoded by gene ( ATP7B) located on chromosome 13 Pathology:  Copper enters the body through the digestive tract with the help of a transporter protein in the cells of the small bowel, copper membrane transporter 1 (Ctr1; SLC31A1).  In response to rising copper levels, an enzyme called ATP7A releases copper into the portal vein to the liver. Liver cells carry the CMT1 protein and metallothionein, and then ATOX1 binds it inside the cell. Once here, ATP7B links the copper to ceruloplasmin and
Read more

59 year old female

Image
This is a case of a 59 year old professor who is a resident of West Bengal. CHIEF COMPLAINT : Case of  Rheumatoid arthritis under medication.   HISTORY OF PRESENT ILLNESS- Patient was apparently asymptomatic an year and half ago.  Then she felt pain in her left wrist joint which was insidious in onset and gradually progressive in nature. It slowly progressed to the hands and shoulder on both the sides with an increased intensity causing difficulty in daily activities and sleep. She used painkillers which provided relief for sometime.  She underwent a physiotherapy for a month. She also took steroid injections twice in a local hospital in West Bengal but the pain reappeared later. There is no history of swellings, morning stiffness, malaise, musculoskeletal pain, weight loss,fever or rash. On February 2022, she went to a specialist in Hyderabad, who suggested her some medications but there was no improvement. Later she went to an OPD in Nalgonda and she got relieved from pain within 10
Read more