Beyond the blog 3

 Ch.Janani

Roll no. 29

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

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 treatment plan 

◇ 61 year old male ,tailor by occupation came to the old with c/0 involuntary movements of bilateral upper and lower limbs (tonic type )

2 episodes while talking to attender which lasted for 5 mins with uprolling of eye since yesterday night

History of present illness : 

Patient was apparently asymptomatic 2 days back while going to washroom with help of walker.patient had blurring of vision and fall on the floor (since then patient is unable to getup from supine position and walk with support )

No h/0 head injury ,no h/0 loc 

Later yesterday in the evening while talking to attenders patient had c/o involuntary movemnets of B/L upper and lower limbs (tonic type)with uprolling of eyes lasting for few mins  and  similar episodes 5 mins apart from the recent  episode 

 No post ictal confusion or tongue bite 

 Or involuntary micturition or frothing of saliva 

History of past illness : 

Patient had H/O right ureteric calculi with concentrated type underwent below knee amputation on Feb 2021 

Pt is K/C/O htn  on tab amalxy 500 mg od

K/C T2DM Intially used insulin now on inj biphasic insulin(5 

And tab.metformin and glimi PO/BD

Not a known case of asthma, epilepsy, CAD, CVA, Thyroid disorders.

Personal history:

He consumes 150 ml per day  whisky for  30 years ,stopped 4 months ago ,non smoker 

Family history:

No significant history

Patient  is conscious,coherent and cooperative 

General examination:

Patient is conscious 

Pallor +

Pedal edema(B/L) +

No icterus, clubbing, cyanosis, koilonychia, generalized lymphadenopathy

Vitals at the time of admission:

Temp- afebrile

PR - 100  BPM

BP - 140/80 mm Hg

Spo2 - 98% at Room air

Grbs: 592 

Rr : 16 cpm 

Temp : afebrile

Systemic examination:

Respiratory system:

BAE+, clear

CVS:

S1, S2 heard

No thrills, Murmurs

Per abdomen:

Soft, non tender

No palpable masses

 

Cns: 

All superficial and deep reflexes are normal

Investigations:

Chest x ray

                                          Provisional diagnosis 

Diabetic ketoacidosis? 

Generalized seizures 

Acute infarct in bilateral occipital lobe with IC (NOF) Of left femur.

Treatment

  

On 3/08/21 and 4/08/21

1. Allowing Soft diet

2.INJ  HA1 SC/ TID

6U-6U-6U

3.TAB LEVIPILL 500mg PO/BD

4.IVF -NS @100ml iv

5.INJ OPTINEURON 1amp in 100ml NS /IV/OD

6.STRICT I/O CHARTING

7.BP/PR/RR/SPO2  CHARTING 4th hrly

8.GRBS CHARTING 4th hrly

On 5/08/21

1.TAB.LEVIPILL 500mg PO/BD

2.IVF-NS@ 75 ml/u

3.INJ OPTINEURON 1 Amp in 100ml NS/IV/OD

4.STRICT I/O CHARTING

5.BP/PR/RR/SPO2 CHARTING 4th

6.GRBS CHARTING 6th hrly

7.TAB AMLONG 5mg/PO/OD

8.TAB METFORMIN +GLIMIPERINE

(500/I/mg/PO)