Suchitha Kola
2019 batch (roll no 65)
Note - This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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.
Case -
A 70 year old female came to the OPD with the chief complaint of sudden involuntary movements since 5 pm yesterday.
History of presenting illness-
The patient was apparently asymptomatic 2 days back.Some time after having food , she experienced SOB on lying in supine position.She was unable to speak suddenly. There was involuntary passage of urine. H/o single episode of vomiting in the night after which she felt better.
The patient did not have any such complaints the next day. Yesterday, the patient did not consume any food from morning till afternoon. Only intake of coconut water and ragi java at around 1pm.
She was just lying and then suddenly she had involuntary movements of the right upper and lower limb at around 4 to 5' o clock associated with aura. She felt weak in those limbs and couldn't get up. She was conscious but her speech was incoherent. No frothing , no tongue bite.
Pt was taken to the nearby hospital in Ramanapet and symptomatic treatment was given after which she was referred to a higher centre i.e. our hospital for seeking treatment. Her last memory was that of sitting in an auto and going to the hospital.
H/o burning micturition since 15 days
History of past illness -
No h/o similar complaint in the past
She is not a k/c/o HTN, DM, TB, bronchial asthma, epilepsy, CAD, CVA
H/o thorn prick to plantar aspect of both right and left foot 25 years back for which proper care was not given. It grew into a huge ulcer which is associated with hypoaesthesia.
Left foot
Right foot
Teatment history - no h/o blood transfusion or any surgeries in the past
Personal history -
She is a home maker. Stays at home the whole day doing her own work, eating and sleeping.
Appetite - normal
Diet - mixed
Bowel & bladder movements - regular
Sleep - adequate
No addictions
No known drug / food allergies
Family history - none of the siblings have had such problem as the patient
General physical examination - The patient is conscious, partly coherent and not well oriented to time, place and person
She is well built and nourished
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema
Vitals(on admission) -
Temp- 98.5 degree F
PR- 70 bpm
BP- 90/60 mm Hg
RR- 26 cpm
SPO2- 94 %
GRBS- 342mg/dl
Systemic examination -
CVS- S1, S2 heard, no murmurs
CNS -
GCS - E4, V4, M6
Gait
RESPIRATORY SYSTEM - NVBS heard, no adventitious sounds
ABDOMINAL SYSTEM- scaphoid, soft, non tender, no organomegaly
Investigations -
Provisional diagnosis- Seizures due to uncontrolled sugars?
Treatment given-
INJ IV FLUIDS(NS/RL/DNS) @UO + 50ML/HR
INJ HUMAN INSULIN 40 U IN 39ML NS IV @6ML/HR INCREASE/DECREASE TO MAINTAIN GRBS< 200MG/DL
INJ KCL 2 AMP IN 500 ML NS/IV @4 HRS
INJ OPTINEURON 1 AMP IN 100 ML NS/ IV OD
INJ LEVIPRIL 1 MG /IV STAT
INJ LORAZ 2 CC / IV STAT OR SOS
PROTEIN X POWDER 1 SPOON IN 100 ML MILK 8 th HOURLY
GRBS MONITORING EVERY HOURLY
BP/ PR/ TEMP EVERY 4 TH HOURLY
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