ACTIVE CLINICAL LEARNING - GENERAL MEDICINE
Roll No-75
Name-Sudarsan sai Mallarapu.
NOTE:
- The following e-log is structured under the guidance of Dr . Raghu Sir
- The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent.
- Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
- This E-log also reflects my patient's centered online learning portfolio.
- 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 providing treatment best to our skills and wisdom.
A 60 years old female presented in the casualty with complaints of vomiting and altered sensorium.
CHIEF COMPLAINTS
➤10 episodes of vomiting➤Generalised weakness➤Drowsiness➤Body pain
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 3 days ago after which she developed high grade fever 1 episode and was taken to a local doctor and was treated for the same (medical records not available). Fever subsided yesterday night.
After dinner she had 10 episodes of vomiting and patient had disturbed sleep and generalized weakness and patient was brought to casualty and admitted in the morning.
HISTORY OF PAST ILLNESS
➤Not a known case of hypertension,diabetes,bronchial asthma,epilepsy and TB➤No H/O of similar complaints in the past.
DRUG HISTORY
➤No significant drug history.
PERSONAL HISTORY
➤Appetite is normal
➤Self care and hygiene not maintained
➤Alcohol consumption 10 years occasionally once in a month (180ml whiskey)
But stopped alcohol intake 6 months back.
➤H/O of consumption of tobacco leaves for the past 5 years (2-3 leaves per day)
FAMILY HISTORY
➤No family history of psychiatric illness.
ALLERGIC HISTORY
➤No significant allergic history
GENERAL EXAMINATION
➤Pallor : Not seen
➤Icterus : Not seen
➤Cyanosis : Not seen
➤Clubbing : Not seen
➤Lymphadenopathy : Not seen
➤Edema : Not seen
➤Malnutrition : Not seen
➤Dehydration: Present
VITALS
➤Temperature : 98.4℉
➤PR : 84 beats per minute
➤BP : 130/70 mmHg
➤RR : 18 cycles per minute
➤SpO2 : 99% in room air
➤Blood Sugar (random) : 186 mg/dl
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM EXAMINATION➤s1 and s2 heard.
➤Thrills absent.
➤No cardiac murmurs.
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present.
ABDOMINAL EXAMINATION
➤Abdomen is soft.
➤Non tender.
➤No palpable mass.
➤Bowel sounds are heard.
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Patient is not cooperative.
➤Patient is conscious .
➤All superficial and deep reflexes are normal.
PROVISIONAL DIAGNOSIS : ALTERED SENSORIUM SECONDARY TO HYPONATREMIA SECONDARY TO VOMITING
INVESTIGATIONS :
DAY 1
NORMAL
MILDLY ELEVATED
HYPONATREMIA-130mEq/L
NORMAL
NORMAL
DECREASED LEVEL OF PROTEIN - 5.1g/dl
SERUM BILIRUBIN IS MILDLY ELEVATED
SGPT IS NORMAL
S.CREATININE IS NORMAL
HB is decreased10.6g/dl
TOTAL COUNT IS ELEVATED-12,900cells/cumm
DAY 3
CHEST X-RAY AP VIEW
DAY 1
➤Patient was referred to psychiatry department for cross consultation.
➤Patient was not cooperative
➤Na- 130 mEq/L
➤Potassium - 3.6 mEq/L
➤Chloride-97mEq/L
➤Hb-10.6g/dl
➤WBC- 12900 cells/cumm
TREATMENT1) TAB.CLONAZEPAM 0.5mg BD
DAY 2
➤C/O headache
➤Fever spikes absent
➤PR-98 beats/min
➤BP-130/80mm of Hg
➤GRBS-135mg/dl
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) INJ.ZOFER 4mg IV/TD
4) ORS sachets 2 in 1 litre
5) BP/PR/TEMP./SpO2 montoring
DAY 3
➤C/O headache
➤Fever spikes absent
➤Patient is conscious and irritable
➤PR-78 bpm
➤BP-160/100 mm of Hg
➤Patient was referred to ophthalmology department for cross consultation
No view of fundus in both eyes due to dense cataract
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) INJ.ZOFER 4mg IV/TD
4) ORS sachets 2 in 1 litre
5) BP/PR/TEMP./SpO2 montoring
DAY 4
➤Headache decreases
➤Fever spikes absent
➤Stools passed
➤Patient is conscious ,coherent and cooperative.
➤PR-86 bpm
➤BP-130/80 mm of Hg
➤GRBS-211 mg/dl
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) IV fluids NS @ 100 ml/hour
4) TAB.PCM 650mg TID
5) INJ.ZOFER 4mg IV/TD
6) ORS sachets 2 in 1 litre
7) BP/PR/TEMP./SpO2 montoring
HISTORY OF PRESENTING ILLNESS
DRUG HISTORY
➤No significant drug history.
PERSONAL HISTORY
➤Appetite is normal
➤Self care and hygiene not maintained
➤Alcohol consumption 10 years occasionally once in a month (180ml whiskey)
But stopped alcohol intake 6 months back.
➤H/O of consumption of tobacco leaves for the past 5 years (2-3 leaves per day)
FAMILY HISTORY
➤No family history of psychiatric illness.
ALLERGIC HISTORY
➤No significant allergic history
GENERAL EXAMINATION
➤Pallor : Not seen
➤Icterus : Not seen
➤Cyanosis : Not seen
➤Clubbing : Not seen
➤Lymphadenopathy : Not seen
➤Edema : Not seen
➤Malnutrition : Not seen
➤Dehydration: Present
VITALS
➤Temperature : 98.4℉
➤PR : 84 beats per minute
➤BP : 130/70 mmHg
➤RR : 18 cycles per minute
➤SpO2 : 99% in room air
➤Blood Sugar (random) : 186 mg/dl
SYSTEMIC EXAMINATION
➤s1 and s2 heard.
➤Thrills absent.
➤No cardiac murmurs.
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present.
ABDOMINAL EXAMINATION
➤Abdomen is soft.
➤Non tender.
➤No palpable mass.
➤Bowel sounds are heard.
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Patient is not cooperative.
➤Patient is conscious .
➤All superficial and deep reflexes are normal.
PROVISIONAL DIAGNOSIS : ALTERED SENSORIUM SECONDARY TO HYPONATREMIA SECONDARY TO VOMITING
INVESTIGATIONS :
DAY 1
|
| NORMAL |
|
| MILDLY ELEVATED |
|
| HYPONATREMIA-130mEq/L |
|
| NORMAL |
|
| NORMAL |
|
| DECREASED LEVEL OF PROTEIN - 5.1g/dl |
|
| SERUM BILIRUBIN IS MILDLY ELEVATED |
|
| SGPT IS NORMAL |
|
| S.CREATININE IS NORMAL |
|
| HB is decreased10.6g/dl TOTAL COUNT IS ELEVATED-12,900cells/cumm |
DAY 3
|
| CHEST X-RAY AP VIEW |
DAY 1
➤Patient was referred to psychiatry department for cross consultation.
➤Patient was not cooperative
➤Na- 130 mEq/L
➤Potassium - 3.6 mEq/L
➤Chloride-97mEq/L
➤Hb-10.6g/dl
➤WBC- 12900 cells/cumm
1) TAB.CLONAZEPAM 0.5mg BD
DAY 2
➤C/O headache
➤Fever spikes absent
➤PR-98 beats/min
➤BP-130/80mm of Hg
➤GRBS-135mg/dl
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) INJ.ZOFER 4mg IV/TD
4) ORS sachets 2 in 1 litre
5) BP/PR/TEMP./SpO2 montoring
DAY 3
➤C/O headache
➤Fever spikes absent
➤Patient is conscious and irritable
➤PR-78 bpm
➤BP-160/100 mm of Hg
➤Patient was referred to ophthalmology department for cross consultation
|
| No view of fundus in both eyes due to dense cataract |
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) INJ.ZOFER 4mg IV/TD
4) ORS sachets 2 in 1 litre
5) BP/PR/TEMP./SpO2 montoring
DAY 4
➤Headache decreases
➤Fever spikes absent
➤Stools passed
➤Patient is conscious ,coherent and cooperative.
➤PR-86 bpm
➤BP-130/80 mm of Hg
➤GRBS-211 mg/dl
TREATMENT
1) INJ.3% NaCl continuous infusion @ 15 ml/hour
2) INJ. PAN 40mg IV/OD
3) IV fluids NS @ 100 ml/hour
4) TAB.PCM 650mg TID
5) INJ.ZOFER 4mg IV/TD
6) ORS sachets 2 in 1 litre
7) BP/PR/TEMP./SpO2 montoring
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