Skip to main content

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

     








   

Comments

Post a Comment

Popular posts from this blog

A 65 year old female e log

  65 year old female patient with seizure December 05, 2023 This is an online e log book to discuss our patient 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 problem with collective current best evident based input. 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 diagnosis and treatment plan. A 65yr old female resident of lingotum with history of seizures  Chief complaints:- .  The patient was brought with chief complaints of Active involuntary movements 5 days back, history of frothing , mouth deviation to left  uprolling eyeball ,no h/o of tongue bite, urinary inc
Post a Comment
Read more

OSCE learning points

Learning points  - This is a case of 65 year old female with Generalised Tonic Clinic seizures  Osce questions 1) Reasons for seizures in old age people  * Neurodegenerative disorders * Cerebrovascular disorders  * Dementia  * Metabolic disorders      - Hypoglycemia      - electrolyte imbalances     - uraemia * Physical or mental exhaustion  2) pathophysiology of seizures  * To function normally brain must maintain a continual balance between excitation and inhibition , remaining responsive to environment while avoiding continued unrestrained  spontaneous activity * GABA inhibitory neurotransmitter acts on ion channels , enhances inflow of chloride and reduces formation of action potential  * Excitatory amino acids allow  influx of sodium and calcium and producing opposite effects  * It is likely that many seizures results from an imbalance between this excitation and inhibition.  ( From Davidson medicine text book ) 3) Drug of choice for different seizure disorders  4) phe
Post a Comment
Read more

GENERAL MEDICINE ASSESSMENT

Name  : Karnekanti Srinija Roll no : 63 Batch : 2019( 3rd semester) JUNE 2021 — BIMONTHLY BLENDED ASSESSMENT   Question No -1 *  First question is to go through the 10 answers of people  in following link and Write a summary on the case , tell about their work  LINK :- (https://generalmedicinedepartment.blogspot.com/2021/06/bimonthly-formative-and-summative_19.html?m=1 ANSWER :  *  I selected the case Regarding Pulmonalogy Here is the summary of the case  — This is a case of 55 year old female patient came to OPD with chief complaints of : shortness of breath ; pedal edema and facial puffiness — The patient is diagnosed with Acute exacerbation of COPD associated with right heart failure and bronchiectasis — she is a known case of Diabetes — The SOB is generally observed during the month of January (during which she works in the paddy field )and her first episode Of SOB observed 20 yrs ago — The systemic examination reveals barrel shaped chest , diffuse apex beat felt at 5 ICS , end ins
Post a Comment
Read more