FINAL MBBS PRACTICAL EXAMINATION-SHORT CASE
Final practicalexam medicine short case
1701006125;( short case)
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 diagnosis and treatment plan
N.Nandini
Hall ticket number; 1701006125
9th semester.
Short case discussion:
75 year old male ,farmer by occupation resident of Aregudem brought to the casualty on 7/6/22
Chief complaints:
Decreased responsiveness since 5 am on 7/6/22 and not able to speak
He was presented to casuality at 10:35 am, with grbs of 43mg/dl
History of present illness
The patient was apparently asymptomatic 15 years back then he had fever,weakness and increased urine output then he visited local hospital and got tested.He was diagnosed as Type 2 diabetes mellitus.He was prescribed with metformin500mg+glimeperide2mg+voglibose0.2 mg
On 7/6/22:
He was unconscious,and not able to speak since 5 am and he was presented to our hospital at 10:35 am with GRBS-43 mg/ dl.
Since last 2 days he had not taken meals and consumed alcohol.
C/O excessive sweating, tremors , generalized weakness, fatigue,lethargy
C/ o decreased urine output since 2 days
No c/o blurring of vision, headache,nausea,abdominal pain,
Past history:
He had similar complaints in the past 6 years ago of decreased responsiveness due to low grbs and was treated in a local hospital with IV fluids
Not a k/c/o hypertension, coronary artery disesase,asthma, epilepsy,
Treatment history:he was on
metformin500mg+glimeperide2mg+voglibose0.2 mg). Since 15 years
Surgery : he underwent for cataract surgery for left eye 2 years ago
Family history : insignificant
Personal history:
Diet : mixed
Appetite : normal
Bowel ; regular
Bladder: decreased urine output
Sleep; adequate
Addictions: chronic alcoholic since 45 years
General examination:
Patient was unconscious at the time of presentation .
Now he was conscious, coherent, cooperative ,moderately built and nourished
Pallor : present( mild)
No icterus,cyanosis,clubbing lymphadenopathy,edema
Vitals
Temperature: afebrile(98.6° f)
Pulse: 52bpm, regular,normal volume
Blood pressure:120/80mmhg
Respiratory rate: 18cpm
Spo2 ;97% @RA
SYSTEMIC EXAMINATION
Respiratory system:
Inspection of upper respiratory tract
BAE-PRESENT
Normal vesicular breath sounds,no wheeze or no adventitious sounds
GIT
Per abdomen:
Cranial nerves;
1 ) olfactory nerve :percieves smell
2) optic nerve :
Visual acuity :decreased in right eye
3) occlomotor nerve :normal
4) trochlear nerve : normal
5) trigeminal nerve :normal
6) abducens nerve :normal
7) facial nerve: normal
8) vestibuli cochlear nerve: normal
9) glossopharyngeal nerve: normal
10)vagus nerve :normal
11) spinal accessory nerve : normal
12) hypoglossal nerve : normal
Gait: normal
Motor system
Power U/L L/L
Right 5/5 5/5
Left 5/5 5/5
Tone U/L L/L
Right normal. Normal
Left Normal Normal
Reflexes Biceps triceps supinator knee ankle
Right 2+ 2+ 2+ 2+. 2+
Left 2+ 2+. 2+. 2+. 2+
Plantar reflex: flexor
Sensory system : normal
Cerebral signs:
Finger nose in coordination:yes
Knee heel in coordination:yes
Investigations:
Complete blood picture:
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