5 2022
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.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.
Shivashankar posham
Roll 125
A 27 year old female patient resident of motkuru came to casuality with
chief complaints
Involuantary movements of right upperlimb for 5 minutes around 9pm last night I,e 4 dec 2022
History of presenting illness
Patients was apparently asymptomatic hours back then she developed sudden onset of involuntaruy movements of right upper limb with twitching pain
No history of tingling, numbness , paresthesia
Patient was taken to private hospital and was investigated that the postassium is 2.2 and calcium is 8.2 mg/dl
And then brought here for further investigation and management
Daily routine
Patient is a daily wage labor in farming
She takes rice thrice a day
She works daily from 9:00 am to 6:00 pm on the farm land
Past history
Patient had similar complaints in the past for 4-5 times which subsides after sometime
No history of DM Hypertension Ashtama epilepsy TB
Family History
No significant family history
Personal history
Diet mixed
Sleep adequate
Appetite normal
Bowel and bladder regular
Treatment history
No significant treatment history
General examination
Patient is consious coherent cooperative
well oriented to time place and person
Moderately built and moderately nourished
Pallor absent
Icterus absent
Clubbing absent
Cyanosis absent
Lympadenopathy absent
Edema absent
Vitals
Temperature Afebrile
Blood pressure 130/80 mmHg
PR 78bpm
RR 17cpm
Systemic examination
Abdomen
Inspection
On inspection abdomen is flat no abdominal distension umbilicus is central and inverted no engorged veins
Palpation
Liver and speen are not palpable
Ascultation bowel sounds heard
Respiratory examination
Trachea central
Normal respiratory movements
Cardiovascular system
S1 S2 heard no murmurs
Central nervous system
Hypotonia of right upper limb
No Reflexes
All other limbs are normotonic
Investigation
Provisional Diagnosis
It was suspected as hypocalcemia but investigations disclosed that the serum calcium is of normal
The next suspection is that it might be a seizures case
Management
Inj Optinerueon
Tab Amitryptiline
IVF NS /RL
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