Assignment: A patient centred learning process

 Greetings to one and all going through my E log

I am M .Devisree gupta ,roll no 81 of 2019 batch


This is  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 patient's problems through inputs from available global online community of experts to slove the patient's clinical problems with collective current best evidence based inputs.

I have been given a task to understand the patient's clinical data analysis and develop my competency in reading and comprehending data like history, clinical findings, investigations,and come up with diagnosis and treatment plan.

CASE : A 68 year old male with altered sensorium.

 Question-1

A 68 year old male patient came to the casualty in an altered state ,with a history of mouth deviated to right.
The patient is non conscious, coherent and cooperative and is not oriented to time ,place and person.
General examination, system examination, respiratory examination, CVS examination,per abdomen examinations are done on patient.
CNS system of the patient are effected .
The power,tone ,reflexes,of the patient are abnormal.

Laboratory investigations of blood urea, serum creatinine, CT scan ,ECG are done to the patient.

Diagnosis:  

The patient is diagnosed as altered sensorium under evaluation and required treatment is given to the patient.

Question-2

Patient history

Chief complaint: Altered state with GCSEV1M4

History of present illness : patient was asymptomatic untill one and half hour ago anh when he was going for nature call and made to sit on the chair then he suddenly became altered with history of fall 

History of deviation of mouth to right
No history of involuntary movements and urinary incontinence
No history of nausea, vomiting
No history of head injury,uprolling of eye balls.
No history of post ictal confusion

PAST HISTORY

K/C/O  Asthma since 14 years and on MDI
K/C/O  HTN since 7 years and on amlong 
K/C/O  of CVA in August 2020 with MCA ischaemic infarct with unresolved AF and inferior wall MI .
Not a K/C/O type 2 diabetes,TB

FAMILY HISTORY

No history of similar complaints in family
No history of DM, TB ,stroke, asthma 

DRUG HISTORY

T.Amlong 2.5 mg PO OD for HTN
T.Amiodarone 150h PO BD

PERSONAL HISTORY

Appetite : normal
Diet : mixed 
Bowel movements: regular
Bladder movements: normal
No known allergies
No addictions

GENERAL EXAMINATION

The patient is non conscious, coherent and cooperative is not oriented to time, place and person
Moderately built and nourished
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing: absent
Edema: absent
Lymphadenopathy: absent

VITALS
  
Temperature: 98.4 F
Heart rate: 132 BPM 
BP : 180/120 mm Hg
SPO2 : 97 percentage
Respiratory rate : 18/ min
GRBS: 151mg %

SYSTEMIC EXAMINATION:

CVS SYSTEM: S1,S2 heard
No added thrills, no murmurs

RESPIRATORY SYSTEM: 
Position of trachea: Central
Breath sounds: Vesicular breath sounds heard
Adventitious sounds: Not heard

PER ABDOMEN:
Soft, non tender, no organomegaly 

CNS:
Level of consciousness: stuporous
Speech: no response 
Cranial nerves could not be evaluated on presentation
7th nerve examination: Deviation of mouth to right side 

On 25/6/21:
Cranial nerves intact 

Motor system:

Power:
Right sided 4+/5 
left UL - 0/5 
LL - 3/5

Tone:
Right side normal tone both UL and LL
LEFT SIDE tone increased in both UL AND LL 

Reflexes: 
RT SIDED

biceps 3+ , triceps 1+ ,supinator 1+,knee 3+, ankle 2+

LT SIDED 

biceps 3+, triceps 3+ , supinator 3+ , knee 3+, ankle 2+

No cerebellar signs 

Investigations

Question -3


1) Serum electrolytes

https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiucUhSdJcbA9fq0INSVIWlAXmR1kX_IlPl0QZksfHwZFYgQlizskMV5GUs-Pc4Frw9VDgTsm85Y4InHwH9nKhcnpxY-bZHiWMpx6BCqbgK3MZvH4zdXg7m4Mj182pgd-dDaIbqmG9TYh_/s720/B652038A-2A9A-48E2-80C6-2ECA6F4E28B5.jpeg

2) Serum creatinine


https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh0UEhXL3MRgJMoOpe_eDNPY3nDC5ItT7iW7DZRaxTOkxSWG27z_X-ovX06Nd2RIebsUI_2B06ijfC0_GqJLtnWnmJc_QTzwhMueD77s2nnTFLO632VHYF4aj-fuMbgf9sEgh2K4DE3zQ90/s710/E3C5F42C-1DBA-483E-9667-A4AB18A51437.jpeg
3) Blood urea

https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZ1mS8OoHgO9NvrJ66ZkuHmIOKq10ZNhffZ7r4dZMcGat59zA_KZaSBPNW41NV2MtvTTDAQY0FP6aLBzNNAx-vbm_kfotJK30UtPoDcVFoy_1hCx6-KrquUTfq9w1NcCQZdMYUpbgeUCSO/s980/63D32F65-FA5B-49EC-B035-833486622662.jpeg

4) CT scan

https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhRH7WSUexemkLWM7HPfJj2cMWts9EVGBQkxjJ1wSw3byDhyphenhyphen5muWdOCri8RffD0_Foz44vUT7by2uKd8YXrGRrbQRL8mcfVTgptXaArsW1-5-TYfcKtHVSOSEdAQgRbr7e6MuDncqQaUwH2/s690/027C2478-E908-4494-8F5E-A3A84384F183.jpeg

5) ECG on 24/6/21

https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUoUV61H0EdzMTug5zA7x5fTK7JQ2UXnOniJZmaV692Uj4A2uLElyb5wIu9KfKY6dFFMlYolQ9yEYODXnNGKI91AKhbBAYxD1D3rY7fEJ4M6bVBh-MWp57RfuPnukgULkrlAqaUecf_I5z/s1015/26CDEBEB-65FA-424A-BE1A-6CF430E093B4.jpeg

6) ECG on 25/6/21


https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhZ1mS8OoHgO9NvrJ66ZkuHmIOKq10ZNhffZ7r4dZMcGat59zA_KZaSBPNW41NV2MtvTTDAQY0FP6aLBzNNAx-vbm_kfotJK30UtPoDcVFoy_1hCx6-KrquUTfq9w1NcCQZdMYUpbgeUCSO/s980/63D32F65-FA5B-49EC-B035-833486622662.jpeg

PROVISIONAL DIAGNOSIS:

Altered sensorium under evaluation 
(Intracranial bleed ruled out)

TREATMENT:

On 24/6/21:
-Tab Nicardia 10mg PO stat

-Tab Ecosporin 150mg PO h/s

-Tab clopitab 75mg PO h/s

-Tab Amlong 2.5mg PO OD

-Tab Atorvas 40 mg PO h/s

-BP charting 4th hourly

On 25/6/21:

-Tab ecosporin 75mg PO

-Inj optineuron 1 ampoule in 100 ml NS OD

-Tab atorvas 40 mg PO

-Tab clopidogrel 75 mg PO

-Tab amlong 2.5mg PO OD

- BP charting 4th hourly

-SYP potchlor 10ml PO BD

-Tab amiodarone 150mg PO BD

Discontinued from the last 4 years

Question-4 

https://pallavi191.blogspot.com/2021/06/gm-cases.html?m=1

CNS case

A 28 year old male patient came to the hospital with the chief complaint of sudden fall, followed by weakness of both lower limbs and loss of hand grip 10 days back, associated with bowel and bladder incontinence.

He is a known case of TB since 1 month and his family has a history of TB .

The patient is conscious, coherent, co-operative and oriented to time, place and person.

System examination,CVS examination, respiratory examination,per abdomen examinations are done on the patient.

Laboratory investigations of blood urea, serum creatinine levels, complete blood profile,serum electrolytes,ECG, chest X ray,MRI are done

DIAGNOSIS:

The patient is diagnosed by quadraparesis secondary to infectious spondylitis of C4,C5,C6,C7,and D1 with epidural abscesses at C5-C6 level.

The patient is given treatment of
1.  Injection optineuron 1 Amp in 100ml. NS IV/OD

2. Injection Thiamine 200 mg in 100 ml NS IV /TID

3.ATT according to body weight 2 tab PO/OD

4. BP /PR/ SPO2 / Temperature charting.


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