ICU bed no 2

-

 E.RISHITHA REDDY

ROLL.NO-30



MEDICAL CASE DISCUSSION:

“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-centered online learning portfolio and your valuable inputs on the comment box is welcome."

I've been given this case, in an attempt to understand the topic of "patient clinical data analysis" and to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations as well as to come up with a diagnosis and treatment plan.


CASE REPORT-





A 67 yr old female came to the casualty with c/o altered sensorium since 2 pm ( 7/9/21) 

History of present illness : 

 Patient was apparently asymptotic before 2 pm (7/9/21) , then she developed altered sensorium sudden in onset .

She had repeated episodes of  fainting from past 6 months with a duration episode of 15 min and after regaining consciousness she couldn’t recognise any thing for few min and then become normal after that.

H/o seizures on/off since 10 yrs 

Patient was normal 6 months back  then developed-loss of speech with altered sensorium.

Past history:

MRI : 6 months back 

Multiple calcified granulomas ( largest measuring 1.0X0.8 cm in the frontal lobe ) 

Chronic laccunar infarcts in pons -on Left side ,B/L basal ganglia 
Small vessels ischaemic changes 

Past history:

No h/o HTN , DM, CAD and any other chronic illness

Personal history:

Appetite:N
Diet :veg 
Sleep :regular
B/B: regular /normal 
No addictions 

Family history:

 Not significant.

Physical examination: 

PICKLE : - ve 

Temp ; afebrile 
PR: 98bpm 
RR: 22
BP :140/90 mmhg 
Spo2 : 98 
GRBS :209 mg%

Systemic examination: 

CVS : s1 s2 +
Respiratory: BAE+,NVBS 
Abdomen : soft , non tender 
CNS : unconscious 
Speech : aphasic 
No signs of meningeal irritation 

Tone : 
Right U/L: increased , L/L- normal 
Left U/L: increased , L/L- normal 

GCS: E1V1M1

Reflexes : knee , ankle - absent 

Investigation reports:

Blood urea-


Serum Creatinine-



Utica acid serum-


Serum electrolytes-


Liver function tests-



ECG-







Provisional diagnosis: 
Altered sensorium under evaluation



Comments

Post a Comment

Popular posts from this blog

30 yrs old female

-
Image
  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-centered online learning portfolio and your valuable inputs on the comment box 30 years old female presented to casualty with  chief complaints of sudden worsening of SOB since one day  History of presenting illness: patient was apparently normal till six years back in 2017 she had generalised body aches and joint pains which involves multiple large joints of which elbow And knee joints  troubled her associated with generalised body aches after multiple hospital visits  she even noticed hair loss without scarring and oral ulcers then she was diagnosed with au
Read more

57yrs old male patient

-
Image
 ICU BED -2   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-centered online learning portfolio and your valuable inputs on the comment box Chief complaints: C/o of constipation since 20 days  C/o  of fever since 4 to 5 days History of presenting illness:  patient came with c/o of constipation since 20 days I was admitted in hospital for three days  C/o of fever high-grade since 4 to 5 days more during night  history of hiccups 15 days back admitted in hospital for three days  no c/o of decreased urine output vomiting headache   chief complaints of decreased appetite since 5 to 6 days History of past illnes
Read more

COVID Case Report

-
Image
E.RISHITHA REDDY ROLL . NO-30 MEDICAL CASE DISCUSSION: “ 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-centered online learning portfolio and your valuable inputs on the comment box is welcome." I've been given this case, in an attempt to understand the topic of "patient clinical data analysis" and to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations as well as to come up with a diagnosis and treatment plan. All the information was obtained from the patient's relative, along with inputs from Dr. Praneeth Reddy sir
Read more