gm E-log log

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 patient's clinical problems with collective current best evidence based inputs. 
Date of Admission: 19/7/22

CHIEF COMPLAINTS 
This is a case of 70yr old male ,who presented to the casualty with Chief Complaints of involuntary movements of upper limbs and lower limb with involuntary micturition 
HOPI
Patient was apparently asymptomatic 5 months back and them he developed brain stroke for which he uses medication which should be continued for lifelong and on 19 July he presented to casualty with an episode of seizure which involved involuntary movements of both upper and lower limbs and involuntary micturition. After admitting he developed another 2 episodes of seizures with involuntary micturition   for which he recieved  inj.lorazepam 2cc  i.v stat , Mannitol 100 ml i.v stat, Inj.levipil 1gm i.v stat. 


PAST HISTORY 
Operated for stones in urinary bladder few yrs  back
Operated on vertebral column few yrs back 

History of CVA Ischaemic Stroke (Rt PCA Stroke )on FEB 2022

Known case of Hypertension 

N/ K/c ,Diabetes,TB,Asthma

TREATMENT HISTORY
Using medication for stroke and HTN


FAMILY HISTORY 

NO relavent family history

PERSONAL HISTORY 

Diet:Mixed type
Appetite: Normal 
Micturition: Normal
Bowel and Bladder movements: Constipation 
Sleep: adequate 
Addictions: 
He used to drink alcohol occasionally (twice a month) and he was a smoker (1 pack of bidi per day) since 20 years. He stopped drinking alcohol smoking from 6 months.

  
GENERAL EXAMINATION
No Sign of Icterus,cyanosis,clubbing,Lymphadenopathy,
oedema. 
- has Blurred vision
VITALS
Temp: Afebrile
Pulse rate:120bpm
Respiratory rate: 20/ min
BP: 210/120 mm Hg
IncoSpO2: 96%
GRBS: 178 mg%
SYSTEMIC EXAMINATION 

C V S : SI and S2 Heard
No murmurs

Respiratory System : BAE+, left IAA crepts  + 

Per abdomen: soft and nontender 

Non palpable no organomegaly.

 CNS: 
 Level of consciousness: stuporous
Speech : Incoherent
Pupils: Anisocoria
No signs of Meningitis
GLASGOW COMA SCALE: E2V2M5

Memory : recent, remote intact

Cranial nerves: 

1-intact

2- vision: decreased vision

colour vision:normal

3,4,6- normal(no restriction of movements of eye)

5-normal( muscles of mastication+sensations of face)

7-normal

8- didn't elicit

9,10,11,12-normal


Motor- tone -normal

Power- 5/5 in b/l lowerlimbs 5/5 in upper limbs

Reflexes :

biceps:b/l:2+

triceps:2+

supinator+2

knee:2+

plantars:b/l flexor


sensory: crude ,pain,temp, fine touch, joint position, proprioception are normal in all dermatomes






INVESTIGATIONS 

On 19/07/2022
2D Echo
ECG



MDCT Scan

On 20/07/2022

On 21/07/2022
On 22/07/2022

On 23/07/2022

PROVISIONAL DIAGNOSIS
SEIZURES under EVALUATION

TREATMENT:

Inj. LEVIPIL 500mg I.v BD

Inj. PIPTAZ 4.5g Iv TID

Inj. PANTOP 40mg I.v OD

Tab AZEE 500mg PO OD

Inj. LORA 2cc I.v SOS

Inj. ZOFER 4mg I.v SOS

Inj. OPTINEURON IN 500 ml NS 1 amp I.v OD.

 

  

Comments

Post a Comment

Popular posts from this blog

BIMONTHLY BLENDED ASSIGNMENT FOR JUNE 2021

 Jella Mounika Roll No: 51 Batch: 2019( 3rd Semester)   I have been given the following assessment to analyze and review, in an attempt to understand the topic of patient 'clinical data analysis' to develop my competency in reading. This is the link regarding assessment:  https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1 QUESTION 01: competency tested for review and assessment Reviewing 10 answers in the link given above.  CASE 01: NEUROLOGY Link: https://aniganikavya06.blogspot.com/ The case was diagnosed as cerebellar ataxia secondary to the cerebrovascular accident which was supported by the patient's chief complaints of slurring of speech, deviation of mouth.              Cerebellar ataxia is due to blockage in the brain which causes decreased blood supply because of that, Oxygen and nutrients to the cerebellum are reduced which ultimately leads to ataxia in the cerebellum.  Patient hypertension and alcoholism have al
Read more

Prefinal OSCE

1.RR in tachypnea?  -The normal respiratory rate (RR) for adults at rest is typically in the range of 12 to 20 breaths per minute. Tachypnea is generally defined as a respiratory rate that exceeds this normal range,  that is respiratory rate higher than 20 breaths per minute in adults considered tachypneic. 2.why there is tachypnea in community acquired pneumonia (CAP)despite a normal SpO2 reading of 99% ?  Reasons for tachypnea in CAP: Ventilation-Perfusion Mismatch: Pneumonia can lead to a mismatch between ventilation (airflow) and perfusion (blood flow) in the lungs. Even with adequate oxygen levels in the inhaled air, the exchange of gases in the affected areas of the lungs may be compromised, triggering a respiratory response. Increased Work of Breathing: The body's effort to overcome the decreased lung function and maintain sufficient oxygen supply to the bloodstream can result in tachypnea, despite the overall oxygen saturation appearing normal. 3.Respiratory findings in Com
Read more

GM - Elog

Image
Name : J. Mounika  Roll no :  51 3rd sem student  This is an online e log book to discuss our patient de- identified health data shared after taking his/ her guardians signed and informed consent.  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 a diagnosis and treatment plan. Case presentation: A 50 year old male, farmer , resident of nagarjunsagar came with OPD with decreased urine output and shortness of breath.  History of present illness •Pedal edema since 3 months • Facial puffiness, decreased urine output since 3 months •shortness of breath since  3 days History of past illness Pt was apparently asymptomatic 3 months back, was admitted & Diagnosed as chronic renal failure with anemia • Dialysis initiated on 15/10/2021, 4 session of HD done, 20 PRBC transferred.  Tre
Read more