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A 67 year old female patient e log

 E-LOG GENERAL MEDICINE


Hi, This is K.Srinija , a eighth 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


A 67 year old female resident of Mothkur housewife by occupation  came to OPD

 CHIEF COMPLAINTS :

- Giddiness since 1 week

HISTORY OF PRESENT ILLNESS 

- Patient was asymptomatic 1 week ago then she suddenly fell down due to Giddiness and got injured , which was sudden in onset and gradually progressive

- she has history of three such episodes in a week

- The last episode is while drinking water , and got injured for which she underwent treatment outside and came to the hospital

- The episode is not associated with any postural changes

- There is no history of tinitus , hearing loss,  headache, vomiting, ear pain , fever , cold , abnormal movements 



HISTORY OF PAST ILLNESS :


- k/c/o seizure disorder since 15 years, on Tab. EPTOIN 200 mg PO/BD


- 15 years back, Patient started having -episodes of seizures where she would have an aura and then fall with thrashing of limbs. The episode was associated with loss of consciousness for 5 minutes and foaming at mouth. There would be confusion after the episode of seizure. She has been using medication since 15 years but would still have occasional episodes. The last episode was 2-3 months ago.


- Not a k/c/o DM, HTN,TB, asthma, CAD,CVA


- H/o Left femoral fracture, treated by placing a femoral nail


Family history : Nil significant


PERSONEL HISTORY :


-Takes mixed diet, 

-Normal appetite

-Bowel and bladder are regular

-Sleep adequate

-Occasionally drinks toddy or beer (once in a month)

-No Allergies


GENERAL EXAMINATION :


Pallor- Absent

icterus- absent

cyanosis- absent

clubbing- absent

Lymphadenopathy - absent

Edema- Absent 




VITALS

Temp: 96.8°F

PR: 82 bpm

RR: 18 cpm

BP: 140/90 mmHg

SpO2: 98% 

GRBS: 115 mg/dl



SYSTEMIC EXAMINATION :


CARDIOVASCULAR SYSTEM

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No


RESPIRATORY SYSTEM

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No


ABDOMEN

Shape - Scaphoid

No tenderness, palpable mass

CNS 

Patient is drowsy

Dominance -Right handed

Higher mental functions

Conscious

Oriented to time place and person

Memory -Immediate, recent and remote 

Slurring of speech 


Tone.                Right.           Left 

Upper limb             Normal

Lower limb             Normal

Power             right         left

Upper limb     4/5            4/5

Lower limb     4/5             4/5 


Deep tendon reflexes Right Left 

Biceps.       ++                          ++

Knee Jerk.  ++                       ++



PROVISIONAL DIAGNOSIS :

Giddiness under Evaluation: ?BPPV, ?Vestibular neuritis, k/c/o seizure disorder since 15 years


INVESTIGATIONS







Treatment given:


1) Tab. LEVIPIL 500 mg PO/BD
2) Tab. VERTIN 8 mg PO/BD
3) Inj. OPTINEURON  10 Amp in 100 ml NS IV/OD
4) Syp. POTKLOR 15 ml in glass of water PO/TID

 3/6/23
AMC

 S

C/o generalized weakness (finding it tiring to go to bathroom)
Stools passed


O
Patient is conscious,coherent, cooperative 
Afebrile to touch
PR- 76 bpm
RR- 24 cpm
BP-  120/60mmHg
Spo2- 99% on RA
I/O: 2800/800 mL

CVS- S1s2present, no murmurs heard
RS-B/L air entry present
PA- soft,NT, bowel sounds heard
CNS - NAD

A
Giddiness under Evaluation: ?BPPV, ?Vestibular neuritis, k/c/o seizure disorder since 15 years

Serum potassium on 3/6: 3.8 mEq/L

P
1) Tab. LEVIPIL 500 mg PO/BD
2) Tab. VERTIN 8 mg PO/BD
3) Inj. OPTINEURON  10 Amp in 100 ml NS IV/OD
4) Syp. POTKLOR 15 ml in glass of water PO/TID


4/6/23
Ward

 S

Giddiness subsided
Stools passed


O
Patient is conscious,coherent, cooperative 
Afebrile to touch
PR- 82 bpm
RR- 20 cpm
BP- 120/60mmHg
Spo2- 99% on RA
I/O: 1800/900 mL

CVS- S1s2present, no murmurs heard
RS-B/L air entry present, NVBS
PA- soft,NT, bowel sounds heard
CNS - NAD

A
Giddiness under Evaluation: ?BPPV, ?Vestibular neuritis, with hypokalemia (resolved) k/c/o seizure disorder since 15 years

Serum potassium on 4/6: 3.5 mEq/L

P
1) Tab. LEVIPIL 500 mg PO/BD
2) Tab. VERTIN 8 mg PO/BD
3) Monitor vitals


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