This is an online Blog book to discuss our patients deidentified health data shared after taking his/ her guardians to sign an informed consent
Here we discuss our patient problems through a series of inputs from the available Global online community of experts with n aim to solve those patient clinical problems with the current best evidence-based input
This Blog also reflects my patient-centred online learning portfolio.
Your valuable input on the comment box is welcome
I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competence in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
CONSENT AND DEIDENTIFICATION :
The patient and the attendees have been adequately informed about this documentation and the privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
PRESENTING COMPLAINTS:
A 38 -year-old patient came to casualty with chief complains of involuntary movements of bilateral upper limbs and lower limbs, face and slurring of speech on & off during nights since 3 days.
HOPI:
Patient was apparently a symptomatic 3days back, Then he started developing involuntary movements of whole body (upper and lower limb ,face) which was sudden in onset and gradual in progression associated with slurring of speech .Each episode lasted for a 10 - 15 minutes . It is relived spontaneously.
Not associated with loss of consciousness ,tongue bite, frothing,unrolling of eye ,defecation,micturition.
PAST ILLNESS:
B/l breast lump (hard , circular mass below nipple) which patient noticed 20 days back
K/C/O Type2 DM since 1and half year .
H/O cataract surgery in right eye.
N/K/C/O HRN/CAD/asthma/epilepsy.
PERSONAL HISTORY:
Appetite normal.
Sleep adequate.
Bowel and bladder are regular.
No allergies.
FAMILY HISTORY:
Mothers has diabetes since
No Comorbidities.
GENERAL PHYSICAL EXAMINATION:
Moderately built and poorly nourished.
Patient was conscious and cooperative.
Oriented to time, place and person.
Pallor, clubbing and lymphadenopathy absent.
Cyanosis, pedal edema are absent.
PR : 75bpm;
BP: 120/70mmHg;
RR: 15cpm;
SpO2: 99%@RA;
GRBS: 20 mg/dl
CVS: S1,S2+;
R/S: BAE+;
P/A: Soft, Non tender, BS+;
CNS: NFND.
Past history
K/C/O Type2 DM since 1and half year .
H/O cataract surgery in right eye.
N/K/C/O HRN/CAD/asthma/epilepsy.
Diagnosis
Hypoglycaemic choreoathetosis sec to insulin overdose
CKD ? Diabetic nephropathy
B/l gynecomastia - breast lump
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