General medicine E-log

32 CH SRILEKHA, 8th sem

This elog depicts the patient -centered approach to learning . This is an online E log book recorded to discuss and comprehend our patients de-identified health data shared , after taking his /her /guardians signed informed consent . This elog also reflects patients centered learning portfolio.

75Y F with involuntary movements of upper ,lower limbs and face since past 5hours.

Chief Complaints:

Patient came to casualty with H/O 2-3 episodes of involuntary movements of right upper and lower limb and face since evening(28/10/23)

History Of Presenting Illness:

Patinet was apparently asymptomatic till today afternoon after she which she started having involuntary movements of right right upper and lower limbs associated with up rolling of eye balls and frothing not associated with involuntary micturation and defecation associated with postictal  confusion for 15-20min.

H/o seizure activity on and off from past 3years and is on medication.

No h/0 fever and head trauma.

K/c/o Hypertension,CVA

Past History:

N/k/c/o  DiabetesTuberculosis,bronchial asthma,epilepsy,CAD.

Personal History:

Diet : Mixed 

Appetite : Normal

Sleep : Normal

Bowel and bladder moments :Regular 

Addictions:None

Family History:

Not significant 

General physical examination:

Patient is unconscious 

Moderately built and nourished.

Pallor: Absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Lymphadenopathy:absent

Pedal edema:absent 

https://youtu.be/gdOiN4BEoeI?si=BFxUZvx--VZukjxF

Vitals:

Temperature - 98F

PR :-78 beats per minute 

BP :- 150/100mm Hg

RR:-26 cycles per minute

GRBS:-135

SpO2-90%

Systemic examination:

Cardiovascular system: 

Inspection-

Shape of chest-Normal  

No precordial bulge.

No dialated veins,scars and discharging sinuses.

No visible pulsations.

Palpation-

 Apical beat felt in 5th intercostal space.

No parasternal heave and thrills

Auscultation-

S1S2 heard 

No murmurs heard

Respiratory system:

-Inspection:

Trachea -appears to be central

Chest appears bilaterally symmetrical ,movements are symmetrical on both sides.

elliptical in shape.

No chest wall defects.

No scars and sinuses.

-Palpation:

All the inspectory findings are confirmed.

Trachea central in position

-Percussion                Right              Left

Supraclavicular          R                   R

Infraclavicular           R                    R

Mammary                   R                    R

Inframammary          R                    R

Axillary                        R                    R

Infraaxillary               R                    R

Suprascapular           R                    R

Infrascapular             R                   R

R-Resonant

-Auscultation        Right              Left 

Supraclavicular     NVBS             NVBS

Infraclavicular       NVBS             NVBS

Mammary           Crepitations.     NVBS

Inframammary      NVBS              NVBS  

Axillary                    NVBS              NVBS

Infraaxillary      Crepitations.       NVBS

Suprascapular        NVBS              NVBS

Infrascapular         NVBS              NVBS

(NVBS- Normal vesicular breath sounds)

Central Nervous system:

GCS-E2V2M4

Tone           Rt.                 Lt

UL               N.                  N

LL.                N.                  N

POWER          Rt.                 Lt

UL                   5/5                 5/5

LL.                  5/5                  5/5

Reflexes         Rt.                   Lt

B                    ++                  ++

T                    ++                  ++

S                     +                  +

K                     +                 +

A                     +                 +

P                       Extension

Per Abdomen:

Soft,non tender 

No organomegaly

Investigations:

Liver Function test:

Total bilirubin-1.61mg/dl

Direct bilirubin-0.34mg/dl

SGOT- 9IU/L

SGPT-13IU/L

Alkaline phosphate-60

Total proteins-7.1g/dl

Hemogram:

Hemoglobin-12 gm/dl

Total count-13800cells/m3

PCV-34.6

RBC-4.32

Platelets:3L

Renal function test:

Urea-33mg/dl

Creatinine-0.7mg/dl

Uric acid -5.6mg/dl

Chloride-102

Sodium-139mEq/L

Potassium-4.1

RBS-115

CUE:

Sugar-nil

Albumin-nil

Pus cells-2-3

Cast cells-nil

RBC-nil

Epithelial cell-2-3

Serology-negative 

              

                        28/10/23

29/10/23

                 30/10/23

                       31/10/23

MRI BRIAN:(Impression)

Chronic infract in left parieto occipital region.

Chronic small vessel ischemic changes

Provisional Diagnosis:

Focal Seizures with impaired awareness with CVA with k/c/o Hypertension.

Treatment:

1) IV fluids DNS,RL 75ml/hr

2) INJ LEVIPIL 1gm iv/od

3)INJ NEOMOL 1gm iv/sos

4)INJ PAN 40mg iv/od

5)INJ LORAZEPAM 2cc iv/sos

6)TAB ECOSPIRIN AV RT

7) TAB PCM 650mg RT/QID

8)NEB MUCOMIST 6th hourly

9) ORAL SUCTIONING 4th hourly

10)MONITOR VITALS