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A 60 year olg female patient elog

  SRINIJA KARNEKANTI 


3rd semester , Roll no : 63


Under the guidance of Dr.Krupa.( Intern)


This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.


I have 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 SCENARIO :

-  A 60 year old female came to the OPD on 9 July 2021  with chief complaints of :

    * Involuntary movements of left        lower and upper limb since 1 week.

   * The frequency of the movements is continuous and through out the day.

   * The movements are with  wild amplitude.

   * There is evidence of slurring of speech.

★ COMPLAINTS AND DURATION :

- The patient is asymptomatic before 1 week and noticed involuntary movements of both left upper and lower limb since 1 week 

- The movements are constant.

- The movements are present at rest 

- There is no increase or decrease history of movements with voluntary movements

- The involuntary movements are not affected by :

         * Posture variation

         * Closure of eyes 

         *  Temperature and environment 

★ HISTORY OF PAST ILLNESS 

- K/C/O of DM , HTN 

★  No H/O of known allergies

★ VITALS :

- Temperature : 98°F

- BP : 100/70 mmHg

- PR : 60 Bpm 

- RR : 22cpm

★ INVESTIGATIONS :

                         ( 9/7/2021)

— SERUM ELECTROLYTES :

* SODIUM : 140 mEq/l                                      { Normal : 136-145}

* POTASSIUM : 3.7 mEq/l                                   { Normal : 3.5-5.1 }

* CHLORIDE : 107 mEq/l                                   { Normal : 98-107 }

— SERUM CREATININE : 0.7 mg/dl                 { Normal : 0.6-1.1 }

— BLOOD SUGAR - RANDOM : 164mg/dl       { Normal : 100-160 }

— BLOOD UREA : 22 mg/dl                               { Normal : 12-42 }

— ABG 

* PH : 7.45 { 7.35-7.45 }

* PCO2 : 31 mmHg { 35-45mmHg }

* PO2 : 76.2 mmHg { 85-95 mmHg }

* HCO3 : 20.9 mmol/L 

* St.HCO3 : 22.8 mmol/L 

* BEB : -2.5 mmol/L 

* BEecf : -1.8 mmol/L 

* TCO2 : 42 .1  VOL

* O2 sat : 93.8% 

* O2 count : 15.2 vol%     

— CBP 

* Hb : 11.2 g/dl { Normal : 12-15 } 

* Total count : 7100 cells/cumm.                      { Normal : 4000-10000 } 

* Neutrophils : 64 % { Normal : 40-80 }

* Lymphocytes : 27% { Normal : 20-40%}

* Eosinophils : 03% { Normal : 1+6% }

* Monocytes : 07% { Normal : 2-10% }

* Basophils : 00% { Normal : 0-2% }

* Platelet count : 2.23 lakhs/cu.mm                 { Normal : 1.5-4.1 }

* Smear : Normocytic Normochromic 

— URINE FOR KETONE BODIES : Positive  (+ve )

— CUE 

* Colour : pale yellow

* Appearance : clear 

* Reaction : Acidic 

* Specific gravity : 1.010 

* Albumin : trace 

* Sugar : Nil 

* Bile salts : Nil 

* Bile pigments : Nil 

* Pus cells : 3-4 

* Epithelial cells : 2-3 

* Red blood cells : Nil 

* Crystals : Nil 

* Casts : Nil 

* Amorphous deposits : Absent 

* Others : Nil 

— GLYCALATED HEAMOGLOBIN HbA1c : 6.7% 

                           ( 11/7/2021 )

 — URINE FOR KETONE BODIES : Negative (-ve)

— POST LUNCH BLOOD SUGAR : 103mg/dl 


                         ( 12/7/2021 ) 

— BLOOD SUGAR - FASTING : 112mg/dl


                          ( 11/7/2021 )



                   



★ TREATMENT :

- Inj PHENARGIN ( PROMETHAZINE )
     25 mg / IM / sos
- T. TETRABENAZINE  12.5mg / BD
- T. GLIMI  M2 / BD
- T. TELMA 40/OD
- GRBS monitoring 
- Moniter BP , PR ,RR
- Inj HAI s/c according GRBS 
- Inj SODIUM VALPROATE 500mg 
         IV in 100 ml NS over 15 min / BD
- T. ECOSPIRIN 75mg / OD
- T. UOPITAP  75 mg / OD
- T. ATORVATATIN  40mg

     








   

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