GENERAL MEDICINE E-log

 E-LOG GENERAL MEDICINE

 Hi, This is Easha chandrika, an eighth semester medical student. This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them.

A 45 YRS OLD WITH PARAPARESIS SECONDARY TO HYPOKALEMIA

Chief complaints:

Weakness of both upper and lower limbs since 4days

HOPI :

Patient was apparently asymptomatic 4 days ago then she developed weakness in both upper and lower limbs but she managed to do her daily activities at home.

Then she could not manage to walk after she got up from bed in the morning and had a fall.

Then she was headed to the hospital in ambulance.In ambulance her BP was 170/80mmHg so driver gave inj:LASIX

HISTORY OF PAST ILLNESS:

Not a k/c/o HTN,DM,epilepsy,asthma,CAD,TB,CVA,thyroid disorder.

H/o:Bilateral renal calculi 

H/o:TAH with bilateral salpingoopherectomy on 23/03/23.

PREVIOUS HISTORY:

No similar complaints in the past.

PROVISIONAL DIAGNOSIS 
Paraparesis secondary to hypokalemia with bilateral renal calculi.

PERSONAL HISTORY:

Appetite:normal

Diet:mixed

Bowel and bladder:regular 

Sleep: adequate 

No addictions

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION:

Patient is conscious and coherent

Moderately built and moderately nourished

Well oriented to time, place and person. 

No pallor

No Icterus 

No cyanosis 

No clubbing 

No lymphadenopathy

No Oedema

No malnutrition 

No dehydration 

VITALS:

Temperature-98.8F

Pulse rate- 88/min

Respiratory rate- 16 cycles/min

BP- 140/70mmHg

SPO2 - 98% 

GRBS-159mg/dl 

CARDIOVASCULAR SYSTEM 

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No

RESPIRATORY SYSTEM

BAE+

Dyspnoea:No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No

ABDOMEN

Shape - Scaphoid 

No tenderness, palpable mass, 

No Fluid 

No bruits

CENTRAL NERVOUS SYSTEM

Level of consciousness - consciouss

Speech - Normal

No signs of meningeal irritation

Cranial nerves - Normal

No motor or sensory deficit 

Tone-both upper and lower limbs normal

Power-upper limbs:4/5(both right and left)

Lower limbs:3/5(both right and left)

Reflexes :        RIGHT              LEFT

Biceps :           +++                     ++

Triceps :           +++                    ++

Supinator :         ++                     ++

Knee :                 ++                    ++

Ankle  :               +                        +

TREATMENT HISTORY:

INJ. Optineuron 1 Amp in 100 ml NS IV/OD

INJ. Kcl 2 Amp in 500 ml NS IV

SYP potchlor 15 ml PO/TID in 1 Glass with water

TAB. Drotin -P PO/ SOS 

TAB .Pan 40mg PO/OD

INVESTIGATION:





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