Hi, I am Manasvi Peddineni, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.
Case Scenario: A 70 year old female came to the OPD with the chief complaint of sudden involuntary movements since 5 pm yesterday.
History of presenting illness-
The patient was apparently asymptomatic 2 days back.Some time after having food , she experienced SOB on lying in supine position.She was unable to speak suddenly. There was involuntary passage of urine. H/o single episode of vomiting in the night after which she felt better.
The patient did not have any such complaints the next day. Yesterday, the patient did not consume any food from morning till afternoon. Only intake of coconut water and ragi java at around 1pm.
She was just lying and then suddenly she had involuntary movements of the right upper and lower limb at around 4 to 5' o clock associated with aura. She felt weak in those limbs and couldn't get up. She was conscious but her speech was incoherent. No frothing , no tongue bite.
Pt was taken to the nearby hospital in Ramanapet and symptomatic treatment was given after which she was referred to a higher centre i.e. our hospital for seeking treatment. Her last memory was that of sitting in an auto and going to the hospital.
H/o burning micturition since 15 days
History of past illness -
No h/o similar complaint in the past. She is not a k/c/o HTN, DM, TB, bronchial asthma, epilepsy, CAD, CVA.
Thorn prick to plantar aspect of both right and left foot 25 years back for which proper care was not given. It grew into a huge ulcer which is associated with hypoaesthesia.
Personal history - She is a home maker. Stays at home the whole day doing her own work, eating and sleeping.
- Appetite: normal
- Diet: mixed
- Bowel & bladder movements: regular
- Sleep: adequate
- No addictions
- No known allergies
Family history -
none of the siblings have had such problem as the patient
General physical examination - The patient is conscious, partly coherent and not well oriented to time, place and person.
- well built and nourished
- No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema
Vitals(on admission)
-temp: 98.5 degree F
- Pulse: 90 bpm
- Blood Pressure: 90/60 mm Hg
- Respiratory Rate: 26 cpm
- SPO2: 94%
-GRBS: 342mg/dl
Systemic Examination:
Cardiovascular System:
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System:
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vesicular
Abdomen:
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- P/R examination : normal
Central Nervous System:
- conscious
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: not seen
- knee heel in coordination: not seen
Clinical Pictures:
Investigations:
Treatment:
INJ IV FLUIDS(NS/RL/DNS) @UO + 50ML/HR
INJ HUMAN INSULIN 40 U IN 39ML NS IV @6ML/HR INCREASE/DECREASE TO MAINTAIN GRBS< 200MG/DL
INJ KCL 2 AMP IN 500 ML NS/IV @4 HRS
INJ OPTINEURON 1 AMP IN 100 ML NS/ IV OD
INJ LEVIPRIL 1 MG /IV STAT
INJ LORAZ 2 CC / IV STAT OR SOS
PROTEIN X POWDER 1 SPOON IN 100 ML MILK 8 th HOURLY
GRBS MONITORING EVERY HOURLY
BP/ PR/ TEMP EVERY 4 TH HOURLY