GENERAL MEDICINE ASSESSMENT

   M easha chandrika

   Rollno:76

   Below is an E-log describing patient centered data approach and discussion regarding patient de- identified health data                                            this e log is made under the guidance of Dr.kranthi mam [intern]

CASEHISTORY:

18 yrs old patient came to casuality 

CHIEF COMPLAINTS;

  weakness of both Lower limbs and was unable to stand and walk

HISTORY OF PRESENT ILLNESS:

▪︎weakness of lower limbs 

▪︎unable to stand 

▪︎unable to walk





HISTORY OF PAST ILLNESS:

▪︎H/o seizure episodes 

▪︎unable to walk till 6 yrs 

▪︎difficulty in studying and writing till  6yrs

▪︎she went for urination and suddenly she couldn't getup on her own she was taken to hospital and was diagnosed hypokalemia 

▪︎she took herbal medication later she developed nausea and vomitings and was taken to hospital and later she was diagnosed Dyselectrolytemia

▪︎then after she developed spasm of upper limbs

▪︎pedal edema (grade 1) 2months back                                                                                                           PERSONAL HISTORY:

▪︎ appetite : normal

▪︎Diet:mixed diet

▪︎micturition: normal 

▪︎ bowel: regular

▪︎known allergies :no 

▪︎no known addictions                                                                                                                                     FAMILY HISTORY:

▪︎no diabetes 

▪︎no hypertension 

▪︎no heart diseases

▪︎no asthma

▪︎no other hereditary diseases 

TREATMENT HISTORY:

▪︎herbal medication for 10 days 

GENERAL EXAMINATION:

▪︎Patient is conscious and coherent 

▪︎palor is present

▪︎no icterus

▪︎ no cyanosis 

▪︎no clubbing 

▪︎no lymphadenopathy 

▪︎no oedema to feet is seen

▪︎No malnutrition 

VITALS:

▪︎pulse rate:82bpm

▪︎ respiratory rate:20/min

▪︎BP:110/70mmhg

▪︎spo2:98%

SYSTEMIC EXAMINATION:

     CARDIOVASCULAR SYSTEM 

        ▪︎heart sounds:s1 , s2

     

     REFLEXES 

                             Rt                 Lt

Biceps                +1                  +1

Triceps                +1                  +1

Supinator            +1                 +1

Knee                     -                     -

Ankle                   -                      -

Plantar                F                    F

  MOTOR :

       TONE: 

                           right            left 

        UL               n                  n

        LL               increased  increased 

                           ( hypertonia)

        POWER:

                          right               left 

          UL           +4/5                 +4/5

           LL 

            Proximal 4/5                4/5

             Distal      3/5                3/5

SENSORY

Touch                 +                       +

Pain                    +                       +

Temperature       +                       +

Vibration:

     UL                +                       +

     LL                   -                      -

Joint position:

     UL                  +                      +

     LL                   -                        -

INTELECTUAL DISABLITY:    +

CEREBRAL SIGNS

        ▪︎finger nose incoordination:no

        ▪︎knee heel incoordination: no

INVESTIGATIONS:

















 
10/07      

 
11/07









PROVISIONAL DIAGNOSIS:

▪︎peripheral neuropathy 

▪︎hypokalemic periodic paralysis

▪︎spastic paraperesis

TREATMENT:
08/07:
1.inj optineuron 1 Amp in 100ml ns
2.tab pregaba -m 
3.tab pcm 650 mg 
4.tab pan 40mg
09/07:
1:inj optineuron 1 Amp in 100ml ns/iv
2: ivf-dns @75ml/hr
3:tab pcm 500 mg/po/sos
10/07:
1:inj optineuron 1 Amp in 100ml ns/iv
2: ivf-dns @75ml/hr
3:tab pcm 500 mg/po/sos
11/07:
1:ivf dns @75ml/hr
2:syp. Potchior 10ml in one glass of water
3:inj optineuron 1amp in 100ml ns
4:tab clonazepam 0.25 mg
12/07 :
1:ivf dns @75ml/hr
2:syp. Potchior 10ml in one glass of water
3:inj optineuron 1amp in 100ml ns
4:tab clonazepam 0.25 mg
13/07: 
1:inj optineuron 1amp in 100ml ns/iv
2:tab clonazepam 0.25mg/po/sos
3:PR monitoring 6th hourly
14/07:
1:t mvt/po/od
2:tab pcm 500mg/po/sos
3:clonazepam 0.25 mg/po/sos
4:PR monitoring 6th hourly 
5:thrombophobe ointment 

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