69 YEAR OLD FEMALE

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.”


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.


69 year old female 

C/O unable to recognise family members since 5 days 

C/O vomiting

Irrelevant talk since 2 days

Patient was apparently assymptomatic 5 days back ,then she had 2 episodes of vomiting after which she had difficulty in speech and generalised weakness,staring look at times, difficulty in walking, patient is unable to recognise her family members .

Patient was bought to the hospital for further evaluation .

Patient has slurring of speech and patient is passing urine and stools involuntarily.

No h/o seizure,head injury 

No h/o fever

H/O similar epusode 10 days back 

Not a k/c/o DM,HTN, Thyroid,Asthma



O/E

Pt c/c/c

Oriented only to person 

Irrelevant talk present intermittently

BP:110/70 mmHg 

PR:80 BPM

CVS:S1S2 HEARD

     no murmurs

RS: decreased breath sounds in b/l ISA

P/A:soft non tender

CNS:

SPEECH- Irrelevant      intermittently

Pupils-NS RL

MMSE couldn't be performed

MOTOR

Power-4/5 in B/L UL and LL

Tone-

       R           L

UL    incd.     Incd

LL      incd.     Incd

Reflexes-

     B T S A K P 

R 2- - -  -  - flexion

 L 2- - - -  - flexion


INVESTIGATIONS:

XRAY 

XRAY 


ECG:

MRI:

DIFFUSE CEREBRAL ATROPHY


ON 01/10/21

SERUM ELECTROLYTES:

Na-127     K-4.5    Cl-104

ON 02/10/21

Serum electrolytes:

Na-132    K-3.8      Cl-92

Serum osmolarity-291 m osm

URINARY ELECTROLYTES:

Na-161     K-35.7      Cl-181

Urinary protein-12

Spot urine creatinine -82.5

03/09/21

Serum electrolytes:

Na-135    K-3.9     Cl-91


04/10/21

Na-135       K-3.9        Cl-91

DIAGNOSIS:

CHRONIC HYPONATREMIA

? DEMENTIA

PSYCHIATRY REFFERAL:


TREATMENT:

Treatment on day 1 

IVF NS ,RL WITH 1 OPTINEURON @75 ML /HR 

INJ.PAN 40MG IV/OD

INJ ZOFER 4MG /IV/SOS 

TAB DOLO 650 MG PO/SOS 

SYP ASCORYL 10 ML /PO/TID

INJ MONOCEF 1GM /IV/BD


Treatment on day 2 


IVF NS ,RL WITH 1 OPTINEURON @75 ML /HR 

INJ.PAN 40MG IV/OD

INJ ZOFER 4MG /IV/SOS 

TAB DOLO 650 MG PO/SOS 

SYP ASCORYL 10 ML /PO/TID

INJ MONOCEF 1GM /IV/BD


Treatment on day 3 



IVF NS ,RL WITH 1 OPTINEURON @75 ML /HR 

INJ.PAN 40MG IV/OD

INJ ZOFER 4MG /IV/SOS 

TAB DOLO 650 MG PO/SOS 

SYP ASCORYL 10 ML /PO/TID

INJ MONOCEF 1GM /IV/BD

TAB ADMENTA 10MG OD(8AM)

TAB OLANZAPINE 5MG OD/HS

INJ HALOPERIDOL 1/2 AMPOULE /IM/SOS


Treatment on day 4

IVF NS,RL WITH 1 OPTINEURON @75ML /HR

INJ.PAN 40MG IV/OD

INJ ZOFER 4MG /IV/SOS 

TAB DOLO 650 MG PO/SOS 

SYP ASCORYL 10 ML /PO/TID

INJ MONOCEF 1GM /IV/BD

TAB ADMENTA 10MG OD(8AM)

TAB OLANZAPINE 2.5MG OD/HS

INJ HALOPERIDOL 1/2 AMPOULE /IM/SOS

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