Hi, I am Yeddula Vishnu Priya, 5th semester medical student. This is an online e log of patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.This elog also reflects my patient centered online learning portfolio
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 diagnosis and treatment plan
A 43 year old male was brought to the casualty with comlains of involuntary movements of body on 8th July morning
HISTORY OF PRESENTING ILLNESS:
The Patient was apparently asymptomatic 6 days back when he had a binge of alcohol . he lost consciousness at his workplace and was taken to the hospital.
At the hospital fluids were given to him and the patient was sent home
In the morning of 8th June 2023 he had 2 episodes of involuntary movement of body lasting for few minutes and relieved on itself.
His wife checked his grbs at home after this episode and it was found to be 60mg/dl after which he was rushed to the hospital.
In the hospital the correction was done inspite of which involuntary movements continued.
He was then brought to our hospital.
No uprolling of eyes or loss of consciousness during the episodes.
No c/o vomitings, headache, frothing from mouth, deviation of mouth, tongue bite, involuntary micturition/defecation.
DAILY ROUTINE :
The patient works as an attender in a college.
He lives with his wife and three children.
He doesn't always follow his routine and go to the college.
He gets up in the morning and freshens up and has breakfast. After his family leaves for work/college, he either goes to college or goes out with his friends and drinks alcohol.
He often skips meals as he forgets about them while he is drinking alcohol. He often consumes food late at night when he is very hungry.
The alcohol consumption has increased in the last 1 year.
On enquiring about the reason of chronic alcoholism with his family, they say that they can't think of any triggers as such.
PERSONAL HISTORY
Diet: mixed
Appetite: lost
Sleep: adequate
Bowel: regular
Micturition: normal
Addictions: drinks alcohol since 20 years, chews gutka since 1 year
Allergies: nil
Family history: not significant
GENERAL EXAMINATION
conscious and coherent.
No signs of pallor, icterus, clubbing, cyanosis, generalized lymphadenopathy, pedal edema
Systemic examination:
CNS EXAMINATION:
The patient is conscious.
Speech: normal
Cranial nerves: intact
Seonsory system: normal
Motor system:
UL LL
Tone R INCREASED INCREASED
L INCREASED INCREASED
POWER
R 5/5 5/5
L 5/5 5/5
REFLEXES R L
BICEPS 2+ 2+
TRICEPS 1+ 1+
SUPINATOR 0 0
KNEE 0 0
ANKLE 0 0
PLANTAR E E
RESPIRATORY SYSTEM EXAMINATION
-Bilateral air entry is present, normal vesicular breath sounds heard.
CARDIO VASCULAR SYSTEM
S1 and S2 are heard. No murmurs are heard
ABDOMINAL EXAMINATION:
Soft, non-tender.
No organomegaly
Bowel sounds are heard.
INVESTIGATIONS
9/07/23
SERUM ELECTROLYTES:
Na: 145
K: 3.2*
Cl: 99
Ca2+: 1.13
Mg2+: 2
Blood urea 20mg/dl
S. Creatinine: 1 mg/dl
RBS: 130MG/DL
LFT:
total billirubin : 0.98mg/dL
Direct bilirubin: 0.20 mg/dL
AST: 45 IU/L
ALT: 30IU/L
ALP: 301* IU/L
Total proteins: 7 gm/dL
Albumin: 4 gm/dL
A/G ratio: 1.25
Hemogram:
Hb: 10.9gm/dL*
Total count: 6,400cell/mm3*
N/L/E/M/B: 75/18*/2/5/0
PCV: 34.6 vol%*
MCV: 78.6fl*
MCH: 24.8pg*
MCHC: 31.5%
RDW-CV:18.2%*
RBC COUNT: 4.40 millions/mm3*
PLATELET COUNT: 1.92lakhs/mm3
Smear
RBC: normocytic normochromic
10/7/23
FBS: 192 MG/DL
PLBS: 294 MG/DL
HBA1c: 6.5%
HEMOGRAM
Hb: 9.7gm/dL*
Total count: 7,800 cell/mm3*
N/L/E/M/B: 70/20*/4/6/0
PCV: 30.2 vol%*
MCV: 70.8FL*
MCH: 25.1pg*
MCHC: 32.1%
RDW-CV:18.2%*
RBC COUNT: 3.8millions/mm3*
PLATELET COUNT: 2lakhs/mm3
Smear
RBC: normocytic normochromic
SERUM ELECTROLYTES:
Na: 139
K: 3.5*
Cl: 101
Ca2+: 1.24
11.07.2023
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