A 24 year old female patient e log

E-LOG GENERAL MEDICINE

Hi, This is K.Srinija , a fifth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

★ CASE SCENARIO

This is a case of 24 year old primi , homemaker presented to Casuality with the chief complaints of

1) Suprapubic pain 4 days back

2)Fever since 4 days

3) Vomitings since 2 days

★HOPI

The patient is apparently asymptotic 4 days back. She developed suprapubic pain which lasted for one day for which she sought for consultation at a local hospital and was diagnosed to be having dengue fever

fever which is of high grade, intermittent associated with chills and rigors relieving on medication

Vomitings of 2episodes/day immediately after consumption of food containing food particles, non bilious,non projectile, non foul smelling, non blood stained

Burining micturition+

No history of loose stools, bleeding gums, rash, hematuria, malena

★PAST HISTORY

She is not a known case of diabetes, hypertension,asthma,cad,epilepsy

★PERSONAL HISTORY

Diet-mixed

APETITE -normal

Sleep-adequate

Bowel and bladder movements -normal

Addictions -none

★FAMILY HISTORY

not significant

★MENSTRUAL HISTORY

Age of menarche -16 years

Cycles- regular 3/28

Pads used per day -3

Bleeding,clotting- absent

★GENERAL EXAMINATION

The patient is conscious coherent cooperative well oriented to time place and person

She is moderately built and nourished

Pallor - absent

Icterus -absent

Cyanosis-absent

Clubbing -absent

Edema -absent

Lymphadenopathy -absent

VITALS

Temp-96F

BP-100/70

RR-16

PR - 82

Spo2 -99

GRBS -102

★SYSTEMIC EXAMINATION

-CVS -s1s2 heard

-PA-vertical scar of 7-8 cm from xiphisternum to below,hypertrophied scar, non tender

-RS-BAE+

-CNS- Higher motor functions intact

★ DIAGNOSIS

Primi with dengue NS1 +

★ INVESTIGATIONS

Malarial parasite -ve

30/8/2022

31/8/2022

1/9/2022

O/E pt c/c/c

Temp : 96 ° F

PR : 104 BPM

BP : 100/70 mmHg

CVS : S1S2 heard

RS : BAE

P/A : scar present

CNS : NAD

- Inj . TAXIM

- IVF

.10 NS ; 10 RL

- Strict I/O charting

-Inj ZOFER

- Inj PAN

- BP/PR/RR/Spoke charting 2nd hrly

31/8/2022

1/9/2022

2/9/2022

3/9/2022

Comments

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 ...

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, ur...

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 involunta...

63 Srinija Karnekanti

Search This Blog