GENERAL MEDICINE CASE DISCUSSION
December 20, 2022
General medicine case discussion
E LOG MEDICINE CASE
20/12/2022
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 protfolio and your valuable inputs on comment box is welcome.
Name : Krishna Pranavi Yallambhotla
Roll no : 61
2020 Batch
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 comeup with Diagnosis and Treatment plan.
CASE DISCUSSION
Date of admission:20/12/2022
A 33 year old female came to opd who is farmer came with,
CHIEF COMPLAINTS
Involuntary movements of right hand since 1:00pm on 19/12/2022.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic one day back. Then she noticed uncontrolled movements of right upper limbs which were preceded by chills . Patient had dizziness in the morning of 19/12/2022.
HISTORY OF PAST ILLNESS
Patient had similar complaints in the past for 3 times which were uncontrolled movements of right upper and left lower limbs. First complaint was 17 years ago, second complaint was 13 years ago, third complaint was 9 years ago.
PAST HISTORY
There is no history of DM,HTN,TB, EPILEPSY.
No history of blood transfusions.
History of LSCS 2 times
PERSONAL HISTORY
Appetite: normal
Diet:Mixed
Bowel and Bladder habits:regular
Addictions: nill
FAMILY HISTORY
No significant family history
GENERAL EXAMINATION:
Conscious, coherent, co-operative
Moderately built,nourished
Pallor: absent
Icterus: absent
Cyanosis:absent
Clubbing of fingers:absent
Lynphadenopathy:absent
Pedal edema:absent
VITALS:
Temperature:99F
Pulse rate:92 beats /min
Respiratory rate:22 Cycles/min
BP:110/80mm of hg
SPO2:99% at room air
GRBS:100 mg%
SYSTEMIC EXAMINATION:
CVS:
S1,S2 Sounds heard,
No audible murmurs
RESPIRATORY SYSTEM:
No dyspnea
Position of trachea:central,
Normal vesicular breath sounds are heard,
No adventitious sounds
ABDOMEN:
Shape of the abdomen:scaphoid
No tenderness
No palpable mass
Normal hernial orifices
Liver and spleen are not palpable
Bowel sounds are heard
CNS:
Conscious
Normal speech
Cranial nerve is normal
Motor system is normal
Sensory system is normal
INVESTIGATIONS
ECG:
PROVISIONAL DIAGNOSIS
Focal seizures
