M VARUN SAI ( INTERN)
This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .
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 .
CHIEF COMPLAINTS :
C/o involuntary movements of both upper and lower limbs - since morning
HOPI :
pt was apparently alright 5 days back then she had fever insidious in onset ,high grade ,increases at night ,not associated with chills and rigors .
SOB since yesterday night , aggravated on exertion , relieved by taking rest ,no orthopnea ,no pnd , no palpitations
Involuntary movements of both upper and lower limbs since morning approximately 10 episodes ( according to attenders) ,uprolling of eyeballs present ,tongue bite present, drooling of saliva present ,involuntary micturation present , no loss of consciousness ,no postictal confusion .
There were 2 episodes of similar involuntary movements when she presented , each episode lasting around 2 to 3 minutes followed by involuntary micturition.
No H/O Headache , vomitings , loose stools , constipation , pain abdomen ,
burning micturition.
PAST HISTORY :
N/k/c/o HTN ,DM, TB, EPILEPSY ,THYROID , CVA , CAD
h/o appendectomy 1 year back.
PERSONAL HISTORY :
Appetite - normal
Bowel and bladder movements - regular
Sleep - adequate
No known drug and food allergies.
GENERAL EXAMINATION :
Pt is conscious , coherent , cooperative
Moderately built and nourished
No pallor , icterus , clubbing , cyanosis , lymphadenopathy , edema.
VITALS :
PR-106bpm
RR-16cpm
BP-140/100mm of Hg
SPo2 -99% at room air
Grbs -221mg/dl on DNS
BP recordings
SYSTEMIC EXAMINATION :
CNS :
Higher mental functions - intact
Cranial nerves - intact
Sensory system - intact
Motor system -
Muscle bulk Right Left
UL Normal Normal
LL Normal Normal
Tone Right Left
UL Normal normal
LL Normal normal
Power Right Left
Right 5/5 5/5
Left 5/5 5/5
Reflexes B T S K A P
Right +2 +2 +1 +3 +2 F
Left +2 +2 +1 +3 +2 F
CVS -
S1 , S2 heard , no murmurs
RESPIRATORY SYSTEM :
Bilateral air entry present
Normal vesicular breath sounds
No added sounds
PER ABDOMEN :
Soft , non tender , non organomegaly, bowel sounds heard
DIAGNOSIS :
?SEIZURES UNDER EVALUATION
INVESTIGATIONS :
DIAGNOSIS :
?HYPERTENSIVE ENCEPHALOPATHY
TREATMENT :
1. IV fluids 100ml NS with optineuron.
2. Inj. LORAZ 2CC IV/SOS.
3. Watch for seizure activity.
4. Tab. Nicardia 20mg po/stat
5. Tab. Telma -H 40mg po/od
6. Tab.levipil 500mg po/bd
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