This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.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 book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is 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.
CHIEF COMPLAINTS:
C/O GENERALISED. WEAKNESS SINCE 3 DAYS.
C/O SOB on exertion since 3 days.
C/O abnormal posturing of upper limb and lower limb with involuntary micturition followed by loss of consciousness , unresponsive since morning 8:00am.
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 5 days back then she fell by slipping from steps for which went to hospital and took medication.
No H/O unconsciousness.
C/O GENERALISED. WEAKNESS SINCE 3 DAYS.
C/O SOB on exertion since 3 days. ( Grade 2).
H/O 1 episode of tonic posturing of upper limb and lower limb with involuntary micturition.
No H/O Tongue bite.
Then since today morning,she was unresponsive, went to hospital @1:00pm today, routine investigation done.
PAST HISTORY:
K/C/O HYPERTENSION SINCE 10 YEARS on medication (Telmisartan-20)
Not a K/C/O DM,TB,CVA,CAD, EPILEPSY,ASTHAMA.
No similar complaints in the family.
Personal history:
Diet- mixed
Appetite- normal
Bowel - regular
bladder movements- regular
Allergies- No
No addictions.
GENERAL EXAMINATION:
Patient is drowsy, GCS - E3,V2,M6. (11/15)
Pallor - yes
no icterus, no Cyanosis, no clubbing, no lymphadenopathy
Vitals day 1:
TEMP-97.7F
BP-70 mmHg on palpatory
PR- 98 bpm
Spo2- 71% at room air
98% with 4 litres of O2
GRBS- 141 mg/dl
Respiratory system : barrel shaped chest.
Trachea is central.
B/L coarse crepts present in all areas.
CARDIOVASCULAR SYSTEM:
S1 S2+
INVESTIGATIONS:
ABDOMINAL EXAMINATION:
Umbilicus inverted , No abdominal distention,no visible pulsations,scars and swelling.
PALPATION: Soft, non tender, no organo megaly.
AUSCULTATION:
BOWEL SOUNDS HEARD.
PROVISIONAL DIAGNOSIS:
? Seizures
with Aspiration
With Shock (?septic)
With Anemia(?Iron deficiency)
With AKI
TREATMENT
1. INJ NORADRENALINE DRIP 10ml/hr
Tappering according to BP.
2. INJ DOBUTAMINE DRIP @5ml/hr
Tappering according to BP.
3. INJ PIPTAZ 4.5gm X IV X STAT followed by
INJ PIPTAZ 2.25 gm X IV X TID
4.INJ PAN 40 mg IV X OD
5.IV NS @50ml/hr
6. Neb with DUOLIN- TID
BUDECORT -BD
8. Strict I/O CHARTING
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