General medicine case discussion

December 23, 2022

 General medicine case discussion

E LOG MEDICINE CASE

23/12/2022

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 : Mamatha 

Roll no : 65

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 : 21/12/2022

A 60 year old female who is a farmer came to causality with ,

Chief Complaints :
 Patient suddenly falls from the bed due to involuntary movements of left upper limb and left lower limb. 

HISTORY OF PRESENTING ILLNESS :
Patient was apparently asymptomatic two days before, she then suddenly developed involuntary movements of both left upper  and lower limbs associated with deviation of mouth and biting of tongue while sleeping and it lasted for about 10 minutes. 

PERSONAL HISTORY :
Diet : Mixed 
Sleep : Adequate 
Bladder and bowel movements : Regular 
Allergies : Nil 
Addictions :  Pan and Occasional alcohol consumption .

PAST HISTORY : 
No history of DM, HTN, TB, EPILEPSY, ASTHMA, CVD. 
No history of previous surgeries. 
No history of blood transfusions. 
 
FAMILY HISTORY : 
Insignificant 

GENERAL EXAMINATION 
Conscious, coherent, cooperative
Thin built , Moderately nourished. 
Pallor : Absent 
Icterus : Absent 
Cyanosis : Absent 
Clubbing of fingers : Absent 
Lymphedenopathy : Absent

INVESTIGATIONS 

ECG :

 

 

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