LIKITHA’S ELOG
Hello everyone! This is Likitha, an intern posted in General medicine department.
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.
Here is a case which I have seen:-
A 38 year old male patient has come to the opd on 04/09/20. He had 2 episodes of involuntary movements of both upper limb and lower limb with frothiness from mouth, up rolling of eyes which lasted for 2 minutes.
No h/o involuntary micturition and tongue bite.
No h/o chest pain, shortness of breath, weakness and deviation of mouth.
The patient had been on maintenance hemodialysis since 10 days.
H/o HTN since 10 days,
He is not a k/c/o asthma, TB, CAD, CVA, epilepsy.
GENERAL EXAMINATION-
Patient is conscious, coherent and cooperative.
Moderately built and nourished.
Vitals -
Temp- Afebrile
Bp- 150/90mmHg
PR- 92bpm
RR- 18cpm
No pallor, icterus, cyanosis , clubbing, pedal edema, lymphadenopathy.
SYSTEMIC EXAMINATION
PER ABDOMEN-
Shape - scaphoid
Tenderness is present in epigastric region
No local rise of temperature
No palpable mass
No organomegaly
Hernial orifices free
Bowel sounds present
RS-
Position of trachea central
NVBS +
No wheeze
No adventitious breath sounds
CVS-
S1S2 heard
No murmurs
Apex beat not felt
CNS-
Higher mental functions intact.
All cranial nerves intact.
Sensory- intact
Motor - intact
No cerebellar signs
INVESTIGATIONS:-
DIAGNOSIS:-
Chronic renal failure on maintenance hemodialysis, k/c/o HTN with generalised tonic clonic seizure.
TREATMENT:-
Inj LEVIPIL 500mg/iv/BD
Inj PAN 40mg/iv/OD
Inj LASIX 40mg/iv/BD
Tab NICARDIA 20mg TID
Fluid restriction <1.5L/day & Salt intake <2gm/day
Tab NODOSIS 550mg/OD
Tab V D3 0.25mcg/OD
Tab SHELCAL 500mg/BD
Tab OROFER XT/OD
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