This is an online E log book to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent.
Name: Sreelekha tondapu
Roll no. - 156
Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E-log also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome.
I've 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
A 43 year old male was brought to the casualty with comlains of involuntary movements of body since today morning.
HISTORY OF PRESENTING ILLNESS:
The Patient was apparently asymptomatic 4 days back when he had a binge of alcohol . he lost consciousness at his workplace and was taken to the hospital. At the hospital, the correction fluids were given and the patient was sent home. Today morning he had 2 episodes of involuntary movement of body (tonic movements with stiffening of body) lasting 1-2 minutes and relieved on itself.
His wife checked his grbs at home after this episode and it was found to be 60mg/dl after which he was rushed to the hospital. In the hospital the correction was done inspite of which involuntary movements continued. He was then brought to our hospital.
No uprolling of eyes or loss of consciousness during the episodes.
No c/o vomitings, headache, frothing from mouth, deviation of mouth, tongue bite, post ictal confusion, involuntary micturition/defecation.
PAST HISTORY:
No similar complains in the past.
K/C/O DM-II since 5 years on insulin. He was diagnosed with DM-II Incidently during an episode of fever for which he was initially prescribed OHA'S. The patient used to skip taking his medication. Due non compliance and very high sugars he was then shifted to insulin.
N/k/c/o HTN, CVA, CAD, Bronchial asthma, thyroid disorders.
DAILY ROUTINE :
The patient works as an attender in a college.
He lives with his wife and three children.
He doesn't always follow his routine and go to the college.
He gets up in the morning and freshens up and has breakfast. After his family leaves for work/college, he either goes to college or goes out with his friends and drinks alcohol.
He often skips meals as he forgets about them while he is drinking alcohol. He often consumes food late at night when he is very hungry.
The alcohol consumption has increased in the last 1 year.
On enquiring about the reason of chronic alcoholism with his family, they say that they can't think of any triggers as such.
PERSONAL HISTORY
Diet: mixed
Appetite: lost
Sleep: adequate
Bowel: regular
Micturition: normal
Addictions: drinks alcohol since 20 years, chews gutka since 1 year
Allergies: nil
Family history: not significant
GENERAL EXAMINATION
Patient is examined in a well lit room after taking an informed consent.
Patient is conscious and coherent.
No signs of pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy, pedal edema
VITAL AT THE TIME OF ADMISSION: (09/07/23)
Temp: 98F
Pulse: 114bpm
RR: 20cpm
Bp:100/80 mm of hg
Spo2: 99% at RA
Grbs:
Systemic examination:
CNS EXAMINATION:
GCS: 15/15
The patient is conscious.
Speech: normal
Cranial nerves: intact
Seonsory system: normal
Motor system:
UL LL
Tone R INCREASED INCREASED
L INCREASED INCREASED
POWER
R 5/5 5/5
L 5/5 5/5
REFLEXES R L
BICEPS 2+ 2+
TRICEPS 1+ 1+
SUPINATOR 0 0
KNEE 0 0
ANKLE 0 0
PLANTAR E E
RESPIRATORY SYSTEM EXAMINATION
-Bilateral air entry is present, normal vesicular breath sounds heard.
CARDIO VASCULAR SYSTEM
S1 and S2 are heard. No murmurs are heard
ABDOMINAL EXAMINATION:
Soft, non-tender.
No organomegaly
Bowel sounds are heard.
PROVISIONAL DIAGNOSIS: SEIZURES UNDER EVALUATION SECONDARY TO ? HYPOGLYCEMIA ? TOXIN MEDIATED
INVESTIGATIONS:
9/07/23
SERUM ELECTROLYTES:
Na: 145
K: 3.2*
Cl: 99
Ca2+: 1.13
Mg2+: 2
Blood urea 20mg/dl
S. Creatinine: 1 mg/dl
RBS: 130MG/DL
LFT:
total billirubin : 0.98mg/dL
Direct bilirubin: 0.20 mg/dL
AST: 45 IU/L
ALT: 30IU/L
ALP: 301* IU/L
Total proteins: 7 gm/dL
Albumin: 4 gm/dL
A/G ratio: 1.25
Hemogram:
Hb: 10.9gm/dL*
Total count: 6,400cell/mm3*
N/L/E/M/B: 75/18*/2/5/0
PCV: 34.6 vol%*
MCV: 78.6fl*
MCH: 24.8pg*
MCHC: 31.5%
RDW-CV:18.2%*
RBC COUNT: 4.40 millions/mm3*
PLATELET COUNT: 1.92lakhs/mm3
Smear
RBC: normocytic normochromic
TREATMENT GIVEN:
INJ. LORAZEPAM 2CC IV/STASTAT
INJ. LEVIPIL 1GM IN 100ML NS IV/STAT
INJ. SODIUM VALPROATE 300MG IN 100ML NS IV/BD
INJ. HAI S/C ACCORDING TO GRBS
INJ. THIAMINE 1AMP IN 100ML NS IV/BD
SYP. POTCLOR 15ml IN 1 GLASS OF WATER
10/7/23
FBS: 192 MG/DL
PLBS: 294 MG/DL
HBA1c: 6.5%
HEMOGRAM
Hb: 9.7gm/dL*
Total count: 7,800 cell/mm3*
N/L/E/M/B: 70/20*/4/6/0
PCV: 30.2 vol%*
MCV: 70.8FL*
MCH: 25.1pg*
MCHC: 32.1%
RDW-CV:18.2%*
RBC COUNT: 3.8millions/mm3*
PLATELET COUNT: 2lakhs/mm3
Smear
RBC: normocytic normochromic
SERUM ELECTROLYTES:
Na: 139
K: 3.5*
Cl: 101
Ca2+: 1.24
11/7/23
USG ABDOMEN:
B/L RAISED ECHOGENECITY OF THE KIDNEY.
