1st internal exam (11-03-2022)

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Gm online assessment

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This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning.  The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever. CASE DISCUSSION : A 65 yr old female coming from Rajavaram ,was brought to the casualty with   CHIEF COMPLAINTS of: Difficulty in moving left upper limbs and lower limbs since 3 days. Weakness in right and left upper limbs and lower limbs since 3 days Inability to speak since 3 days. HOPI Patient was apparently asymptomatic 3 days back she developed weakness in Saturday in left upper and lower limbs which was sudden in onset , gradually progressed and is completely unable to move since 3 days. She is also unable to speak due to deviation of mouth later that day Next day ,the weakness of both limbs of left side became severe and completely lost her speech and not responding to commands. She lost her co...
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A 76YR OLD MALE DIAGNOSED WITH IRON DEFICIENCY ANEMIA

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A 76YR OLA MALE OF: Diagnosis: SEVERE IRON DEFICIENCY ANEMIA HEART FAILURE ( EF - 57%) ACUTE GASTROENTERITIS ( RESOLVED) SLIDING HIATUS HERNIA, GERD  Case History and Clinical Findings : A 77 YEAR OLD MALE PRESENTED TO THE CASUALITY AND PRESENTED WITH THE COMPLAINTS OF VOMITINGS , LOOSE STOOLS AND GENERALIZED WEAKNESS SINCE ONE DAY. THE PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE INVESTIGATIONS WAS PROVISIONALLY DIAGNAOSED WITH SEVERE IRON DEFICIENCY ANEMIA WITH HEART FAILURE ( EF - 57%) HEART FAILURE ( EF - 57%)ACUTE GASTROENTERITIS ( RESOLVED),SLIDING HIATUS HERNIA, GERD. THE PT WAS STARTED ON CONSERVATIVE MANAGEMENT ( IV FLUIDS NS/RL @ 100ML/HR , INJ CEFTRIAXONE 1 GM IV/BD ( 8 AM-8 PM) INJ PAN 40MG IV/TID ( 7AM-2PM-8PM) , INJ ENESET 8MG IV/TID ( 8AM-2PM-8PM) TAB ROSUVASTATIN 20MG H/S (9 PM) TAB ECOSPRIN 75MG PO/OD (8 AM), TAB CLOPRIDOGREL 75MG PO/OD ( 2 PM) , TAB PROLOMET 25 MG PO/OD ( 8AM) TAB BISACODYL 5MG (8PM 2 TABS) INJ IRON SUCROSE 200MG IN 100ML NS IV/OD , SYP G...
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A 45YR OLD FEMALE DIAGNOSED WITH ANEMIA SECONDARY TO B12 DEFICIENCY

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Diagnosis : BAKER CYST ATROPHIC FUNDAL GASTRITIS ANEMIA SECONDARY TO B12 DEFICIENCY  Case History and Clinical Findings:  C/O SWELLING IN THE LEFT POPLITEAL REGION SINCE 3 MONTHS C/O PAIN OVER SWELLING SINCE 2 DAYS  HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC3 MONTHS AGO THEN SHE DEVELOPED PAINLESS SWELLING IN THE LEFT POPLITEAL REGION WHICH INCREASED IN SIZE NOW MEASURING APPROXIMATELY C/O PAIN ASSOCIATED WITH SWELLING SINCE 2 DAYS SUDDEN IN ONSET,DRAGGING TYPE,NON RADIATING NO H/O FEVER NO H/O VOMITINGS,NAUSEA.  PAST HISTORY: NOT A K/C/O DM,HTN,ASTHMA,TB,EPILEPSY,CVA,CAD  H/O TONSILLECTOMY DONE 10 YEARS BACK  GENERAL EXAMINATION:  PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE,WELL ORIENTED TO TIME,PLACE AND PERSON. NO PALLOR,ICTERUS CYANOSIS,CLUBING,LYMPHADENOPATHY,EDEMA. VITALS: TEMPERATURE:98.6 BP:120/80 MM HG PR:87 BPM RR:18 CPM  SYSTEMIC EXAMINATION:  CVS:S1,S2 HEARD NO MURMURS.  RS:BAE +,NO MURMURS  CNS:NO FOCAL NEUROLOGICAL DEFICI...
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