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
11-08-2022
A 21 years old female P2L2 delivered 10 days back NVD - live male baby of 3.5kgs, housewife by occupation brought with complaints of
*Headache since Morning
*1 episode of involuntary movements at 12am
History of present illness
Patient was apparently asymptomatic 1 day back then complained of headache since morning, 1 episode of involuntary movements pattern of tonic clonic seizure at around 12am today
H/o frothing from mouth
No H/o tongue bite
No h/o involuntary micturition and defecation
Episode lasted for 2 mins
Post ictal confusion present.
PAST HISTORY: Not a k/c/o DM,htn,tb,asthma,epilepsy
PERSONAL HISTORY:
She is Married
She consumes
Mixed diet
Sleep is adequate
Appetite normal
bowel and bladder movements are regular
MENSTRUAL HISTORY:
Age at menarche:12 years
Cycle: 30/5 days, Normal flow.
OBSTETRIC HISTORY:
Age at Marriage:19 years
1st pregnancy: conceived after 1 month of pregnancy,NVD,
2nd pregnancy: conceived after 6 months of 1st pregnancy NVD.
FAMILY HISTORY:
No similar complaints in family
General examination:
On presentation: Patient conscious, coherent, cooperative, well oriented to time place and person.
Pallor present
Vitals:
Bp:120/80
Pr:130bpm
Rr:24cpm
Temp:98.2f
Grbs:84mg/dl
Spo2:97%
SYSTEMIC EXAMINATION:
CVS:s1,s2 +
Rs:bae+
P/a: size of uterus:corresponding to 12wks
CNS: b/l pupils NSRL
R L
Tone: N. N
Power: 5/5. 5/5
Reflexes : B T S A K P
R: + + + + + Flexion
L : + + + + + Flexion
No neck stiffness
Kernigs negetive
Brudzinski negetive
INVESTIGATIONS:
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