GENERAL MEDICINE E-LOG

SUPRIYA GAGIREDDY 42

Hi,I am supriya 8th sem medical student.This is an online elog book to discuss our patients 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 problems with collective current best evidence based inputs.This E-log book reflects my patient centered online portofolio         

75Y F with involuntary movements of upper ,lower limbs and face since past 5hours


Chief Complaints:

Patient came to casualty with H/O 2-3 episodes of involuntary movements of right upper and lower limb and face since evening(28/10/23)


History Of Presenting Illness:

Patinet was apparently asymptomatic till today afternoon after she which she started having involuntary movements of right right upper and lower limbs associated with up rolling of eye balls and frothing not associated with involuntary micturation and defecation associated with postictal  confusion for 15-20min.

H/o seizure activity on and off from past 3years and is on medication.

No h/0 fever and head trauma.

K/c/o Hypertension,CVA

Past History:

N/k/c/o  DiabetesTuberculosis,bronchial asthma,epilepsy,CAD.

Personal History:

Diet : Mixed 

Appetite : Normal

Sleep : Normal

Bowel and bladder moments :Regular 

Addictions:None

Family History:

Not significant 

General physical examination:

Patient is unconscious 

Moderately built and nourished.

Pallor: Absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 
 





Vitals:

Temperature - 98F

PR :-78 beats per minute 

BP :- 150/100mm Hg

RR:-26 cycles per minute

GRBS:-135

SpO2-90%

Systemic examination:

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Auscultation-

S1S2 heard 

No murmurs heard

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.


Palpation:

All the inspectory findings are confirmed.

Trachea central in position

-Percussion                Right              Left

Supraclavicular          R                   R

Infraclavicular           R                    R

Mammary                   R                    R

Inframammary          R                    R

Axillary                        R                    R

Infraaxillary               R                    R

Suprascapular           R                    R

Infrascapular             R                   R

R-Resonant

-Auscultation        Right              Left 

Supraclavicular     NVBS             NVBS

Infraclavicular       NVBS             NVBS

Mammary           Crepitations.     NVBS

Inframammary      NVBS              NVBS  

Axillary                    NVBS              NVBS

Infraaxillary      Crepitations.       NVBS

Suprascapular        NVBS              NVBS

Infrascapular         NVBS              NVBS

(NVBS- Normal vesicular breath sounds)

Central Nervous system:

GCS-E2V2M4

Tone           Rt.                 Lt

UL               N.                  N

LL.                N.                  N


POWER          Rt.                 Lt

UL                   5/5                 5/5

LL.                  5/5                  5/5


Reflexes         Rt.                   Lt

B                    ++                  ++

T                    ++                  ++

S                     +                  +

K                     +                 +

A                     +                 +

P                       Extension
Per Abdomen:

Soft,non tender 
No organomegaly

Investigations:

Liver Function test:

Total bilirubin-1.61mg/dl

Direct bilirubin-0.34mg/dl

SGOT- 9IU/L

SGPT-13IU/L

Alkaline phosphate-60

Total proteins-7.1g/dl

Hemogram:

Hemoglobin-12 gm/dl

Total count-13800cells/m3

PCV-34.6

RBC-4.32

Platelets:3L

Renal function test:

Urea-33mg/dl

Creatinine-0.7mg/dl

Uric acid -5.6mg/dl

Chloride-102

Sodium-139mEq/L

Potassium-4.1

RBS-115

CUE:

Sugar-nil

Albumin-nil

Pus cells-2-3

Cast cells-nil

RBC-nil

Epithelial cell-2-3

Serology-negative 


28/10/23






29/10/23



                 30/10/23


                       31/10/23




MRI BRIAN:(Impression)

Chronic infract in left parieto occipital region.
Chronic small vessel ischemic changes






Provisional Diagnosis:

Focal Seizures with impaired awareness with CVA with k/c/o Hypertension.

Treatment:

1) IV fluids DNS,RL 75ml/hr

2) INJ LEVIPIL 1gm iv/od

3)INJ NEOMOL 1gm iv/sos

4)INJ PAN 40mg iv/od

5)INJ LORAZEPAM 2cc iv/sos

6)TAB ECOSPIRIN AV RT

7) TAB PCM 650mg RT/QID

8)NEB MUCOMIST 6th hourly

9) ORAL SUCTIONING 4th hourly

10)MONITOR VITALS



 


Comments

Post a Comment

Popular posts from this blog

BIMONTHLY BLENDED ASSESSMENT - JUNE 2021

NAME:G.SUPRIYA REDDY ROLL NO:42  Question 1: Competency tested for Peer to peer review and assessment : Please go through one particular answer of ten students in this link:  https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1 and share your peer review of each answer with your quantitative marking input as well as qualitative insights into what was good or bad about the answer.  1 PULMONOGY   REVIEW: https://akash688.blogspot.com/2021/05/online-blended-bimonthly-assessmentmay.html   CASE:https://soumyanadella128eloggm.blogspot.com/2021/05/55-year-old-female-with-shortness-of.html   This is a case of Acute exacerbation of COPD associated with right heart failure and bronchiectasis.She is presented with shortness of breathe,genaralised weakness,facial puffiness,drowsiness and decreased urine output.She is a known case of Diabetes Mellitus for the past 8 years.She is a known case of Hypertension.The treatment for all the symptoms has gi
Read more

General medicine case discussion

Image
 G. Supriya reddy 42 67 year old male, sarpanch by occupation resident of nalgonda came with chief complaints of  cough since 1month and  breathlessness since 1month. HISTORY OF PRESENT ILLNESS Patient was apparently normal 1month back. Later he developed shortness of breath since 1 month. Increased on lying down, exertion, decreased on sitting position, taking rest. History of wheeze, cough since 1month with expectoration, mucoid, non foul smelling, No diurnal or postural variation, h/o decreased urine output since 1week.H/o pedal edema since 1week . Loss of appetite, no loss of weight. H/o chest pain, abdominal distension, Tendernrss, pain and fever.  HISTORY OF PAST ILLNESS H/o similar complaints  in past since 2years. Not a known case of Hypertension, diabetes mellitus, CAD.  No history of TB or covid 19 PERSONAL HISTORY APPETITE-Normal Mixed diet BOWELS-Regular MICTURITION-Decreased urine output since 1week ADDICTIONS-Occasional alcoholic, beedi 40/day FAMILY HISTORY No family his
Read more

GENERAL MEDICINE E-LOG

Image
  42  SUPRIYA GAGIREDDY 3rd sem Under the guidance of deepika mam INTRODUCTION : CASE HISTORY AND CLINICAL FINDINGS : 19 year female came to casuality with chief complaints of  2-3 episodes of vomitings ,which is non projectile .Non bilious associated with food particles.5 days back high grade fever.Intermittent ,relieved on medication. Fever subsided 1 day back. HISTORY OF PRESENT ILLNESS : No H/o cold,cough,SOB,Headache Pain abdomen,loose stools Hematuria,Malena,Rash No other complaints PAST ILLNESS : No H/O DM,HTN,ASTHMA,EPILEPSY,CAD,TB PERSONAL HISTORY : No significant personal history FAMILY HISTORY : No significant history GENERAL EXAMINATION VITALS : TEMPERATURE:AFEBRILE PR:96BPM RR:18CPM BP:100/70MMHG SPO2:98%AT RA GRBS:150MG/DL SYSTEMIC EXAMINATION : CVS :S1,S2 HEARD RESPIRATORY SYSTEM :BAE+ NVBS HEARD PER ABDOMEN :SOFT' NON TENDER CNS :NFND INVESTIGATIONS : ECG-NO SIGNIFICANT CHANGES HEMOGRAM:1/8/2021 HB12.77GM TLC4300 CELLS/CU MM PLATELETS:54000CELLS /CU MM RBC:NORMOCYTI
Read more