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
29/10/23
30/10/23
31/10/23
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
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