THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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.
03- March-2022
A 59Y/F brought to the casualty with c/o involuntary movements of B/L upper limbs and lower limbs ,GTCS type , with uprolling of eye, tongue bite, involuntary micturition, lasting for 2 min , with post ictal confusion and no aura.
H/o vomitings since 3 days
H/o pain abdomen since yesterday diffuse type,
No c/o cold, cough, fever, burning micturition, headache ,trauma
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 days ago then she developed vomiting, non projectile, non bilious that contained food particles and water, 10 -12 episodes per day.
She was taken to hospital in Nalgonda twice but her symptoms didn't subside. During her visit to another doctor at Hyderabad , patient developed seizures.
Revolutionary movements, GTCS with up rolling of eyes, drooling of saliva, involuntary micturition, tongue bite and post episodic confusion for 30 minutes. Aura was absent.
After the episode the patient became unconscious and then was brought to our OPD.
No history of trauma, headache, cold , fever, cough .
PAST HISTORY
Not a known case of diabetes, hypertension, tuberculosis leprosy, epilepsy, coronary heart disease , bronchial asthma
PERSONAL HISTORY
Diet- Mixed
Appetite -Normal
Bowel and bladder- Regular
Sleep- Adequate
Addictions- None
Allergies- None
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
Patient had altered sensorium
Moderately built and nourished
Pallor -Absent
Cyanosis -Absent
Clubbing of fingers/toes -Absent
Edema of feet -Absent
Icterus -Absent
Lymphadenopathy -Absent
VITALS
Pulse Rate - 74 /min
Temperature - 98.5 F
Respiration Rate - 18/ min.
BP - 120/70 mm Hg
Spo2 - 99 %
GRBS - 160 mg%
SYSTEMIC EXAMINATION
CARDIO VASCULAR SYSTEM
S1 and S2 heard
No added thrills and murmurs
RESPIRATORY SYSTEM
Normal vesicular breath sounds heard, BAE +
PER ABDOMEN
Soft, non-tender
CENTRAL NERVOUS SYSTEM
1.Level of Consciousness
Conscious and Drowsy but Arousable
2. Speech - Incoherent
3. Signs of Meningeal Irritation
a) Neck Stiffness-No
b) Kerning's Sign-No
4.Cranial nerves NAD
5.Sensory System NAD
6.Motor System NAD
7.Glasgow Scale
E4V2M6
8. Reflexs
Pupils : B/l Nsrl
RIGHT LEFT
PUPIL. NSRL NSRL
TONE. UL NORMAL NORMAL
LL NORMAL NORMAL
POWER. UL NORMAL NORMAL
LL NORMAL NORMAL
REFLEXES
a) BICEPS. 2+ 2+
b) TRICEPS 2+ 2+
c) SUPINATOR 2+ 2+
d) KNEE. 2+ -
e) ANKLE 2+ 2+
f) PLANTAR extensor extensor
Cranial nerves NAD
Sensory System NAD
Motor System NAD
PROVISIONAL DIAGNOSIS
Seizures secondary to hyponatremia
INVESTIGATIONS
ABG
PH 7.44
PCO2 24.0
PO2 107
HCO3 16.1
ST HCO3 20.0
HEMOGRAM:
HB: 13.5
TLC: 16,800
N/L/E/M/B: 86/09/01/05/00
PCV: 38.1
MCV: 80.8
MCH: 28.6
RBC:4.72
RDW-CV :12.6
RDW-SD: 41.7
PS: NC/NC
PLT:-1.1
CUE-
Alb :+
Sugars:nil
Pc:4-5/Hpf
RBS 164mg/dl
Serum electrolytes
Urine electrolytes
Urinary chloride 156 mmol/L
Spot Urinary Potassium 21 Q
Spot Urine Sodium 122 mmol/L
Serum for osmolality 269 m OSM/L
2D ECHO
ECG
USG
X RAY
OTHERS
PROGRESS NOTES
1.Ivf - 3% Nacl @ 15ml/hr to be I/D A/to sr.electrolytes 4th hrly
2.inj monocef 1gm/iv/bd
3.inj pan 40mg/iv/od
4.inj zofer 4mg/iv/sos
5.inj neomol 100ml /iv/ if temp > 101.1°F
6.Monitor vitals 2nd hrly
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