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:
Comments
Post a Comment