41yr male with involuntary movements of upper limb

 August 24, 2022

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.


Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.


This E-blog also reflects my patient's centred online learning portfolio.


I have 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.

Our 41yr old male patient came to the opd with chief complaints of  

Generalised body pains  and involuntary movements of upper limbs since 2days

HOPI

Patient was apparently asymptomatic 6years ago then  developed  neck pain and giddiness for which he went to RMP and was diagnosed having hypertension and then 4years back he developed  chest pain which is dragging type of pain not associated with sob, palpitations for which he went to hospital and got an ecg and    angiogram done , used blood thinners  as advised by them and then he developed giddiness for which he went to RMP and diagnosed to be having DM. 

Later 6months he got fever, generalised body pains and involuntary movements of upper limb and came to our hospital and then he was diagnosed as liver infection.

Now he came to our hospital for same complaints generalised body pains and involuntary movements of upper limb since 2days and was admitted in our hospital.

Past history

K/c/o HTN since 6years 

K/c/o DM since 3years

Personal history

Diet: mixed 

Appetite:normal  

Sleep: adequate

Bowels:Regular 

Micturition:Normal 

Alcoholic but stopped  7months ago 

Stopped smoking 10yrs ago 

Family history:

Not significant

General examination:

Patient is c/c/c 

Temp:98.6F 

PR:74bpm 

RR:16cpm 

No pallor 

No Icterus 

No cyanosis 

No clubbing 

No lymphadenopathy 

Pedal edema present 

Systemic examination:

CVS:S1 S2 sounds heard 

RS:BAE+clear 

P/A: soft and non tender 

CNS: NAD 





ECG on 24/08



ECG on 25/08


2D ECHO






USG

Fever chart


Hemogram

24/08/2022

25/08/2022








RBS: 190 mg/dl 


                                   RFT


                                 LFT
 


Diagnosis:

CLD with portal hypertension pancytopenia.

Treatment:

IV fluids 1U NS @100ml/hr 

Inj TAXIM 1gm IV BD

Inj PAN 40mg IV /OD 

Inj.OPTINEURON 1amp in 100ml NS IV/OD 

Syp lactulose 15ml PO/HS

Strict I/O charting 

Monitor vitals









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