GM case 15. 21/09/2023 85 year female with involuntary movements

Hi, I am P.Kathyayani, 5th sem medical student. 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 patients 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 comment box is welcome. 

I've 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout this piece of work whatsoever.

Chief Complaint:

-85 year old female resident of Narketpally,home maker by occupation came to casuality with chief complaints of  involuntary movements at 2:30 AM.

History of Present Illness:

-Patient was apparently asymptomatic till 2:30 AM then she developed involuntary movements of all four limbs with uprolling of eyes,involuntary micturation, confusions,loss of consciousness,after which patient is being transported to hospital .

-GRBS was 29 mg/dl and was given 25% dextrose following which patient improved in sensorium.

No c/o chest pain, palpitations,SOB,fever,pain abdomen, vomiting,loose stools,cough,cold.

Daily Routine: 

Before she got sick, she used to wake up at 5am every morning, cook for her and her husband, take a bath at 6.30am, wash clothes and dishes by 10 am, eat breakfast of rice and curry .She is a  home maker by occupation. She would cook dinner of rice and curry at 7 pm eat and sleep by 11pm.

Past History:

-No similar complaints in the past.

-k/c/o DM-2 since 13 years on medication Insulin Mixtard x-x-80.

-k/c/o HTN since 12 years on medication

Tab.TELMA 40 mg PO/OD.

-h/o cervical carcinoma 30 years ago.

-Not k/c/o CAD,CVA,Asthma,TB, epilepsy,thyroid disorders.

Surgical history: 

Operated for cervical carcinoma 

Personal History:

- married

- appetite  normal 

- mixed diet

- regular bowels

- abnormal micturition 

- no known allergies 

- addictions: no known addictions

Family History: not significant 

General Examination:

I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, coherent and cooperative

- well oriented to time and space

- well built and adequately nourished

- no pallor 

- no icterus

- no cyanosis 

- no clubbing of fingers 

- no lymphadenopathy 

- no edema of feet

- no malnutrition 

- no dehydration 

Vitals:

- Temperature: afebrile 

- Pulse: 101 beats/ min

- RR: 19 cycles/min

- BP: 160/80 mm Hg measured in right          arm in supine position.

Fluid Intake and Urine Output

Systemic Examination:

Respiratory System

- upper respiratory tract : oral cavity, nose & oropharynx appear normal

- chest is bilaterally symmetrical 

- respiratory movements appear equal on both sides and of thoracoabdominal type

- position of trachea : central

- vesicular breath sounds : present

- no wheeze 

Cardiovascular System:

Inspection :

- shape of chest : elliptical

- no engorged veins, scars, visible pulsations

Palpation :

-Apex beat can be palpable in 5th intercostal space

- no cardiac thrills 

Auscultation : 

- S1,S2 are heard

- no murmurs

Abdomen:

- shape: scaphoid

- no tenderness

- no palpable mass

- no bruits

- no free fluid

- hernias orifices: normal

- liver: not palpable 

- spleen : not palpable

- no bowel sounds

- genitals: normal 

- speculum examination : normal

- P/R examination : normal 

Central Nervous System:

- conscious 

- normal speech

- no neck stiffness

- no Kerning's sign

- cranial nerves: normal

- sensory : normal

- motor: normal

- reflexes: all present bilaterally

                 BICEPS       TRICEPS     KNEE

RIGHT       +2                 +2               +2

LEFT          +2                  +2               +2

                 SUPINATOR    ANKLE   

RIGHT         +2                  +1

LEFT            +2                  +1

- finger nose in coordination: not seen 

- knee heel in coordination: not seen

- gait: normal

Investigations:

-Hb: 6.9

-PCV: 20.5

-TLC: 4400

-Platelet count: 1.60

-GRBS : FBS-70

-B.urea : 17

-S.creatinine : 1.3

-S.Na+: 141

-S.k+: 3.6

-S.cl: 102

-T.Bilirubin: 0.57

-D.Bilirubin: 0.20

-SGPT: 10

-SGOT: 19

-Alk.phosphate: 457

-T.proteins: 7.2

-Albumin: 3.7

-A/G ratio: 1.06

-S.calcium: 10

USG:

2D ECHO :

ECG:

Provisional Diagnosis:

Hypoglycemia secondary to insulin overdose

Treatment:

1.Inj.HAI s/c TID

2.TAB.TELMA 40mg PO/OD

3.Inj.Iron Sucrose