74 yr old female



 A 74 yr old female came to the casuality with altered sensorium on evening (4/10/2021) 

8/10/2021

Sai prasanna.k

3rd sem 

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

H/o past illness 

25yrs back she was diagnosed as hypertension and diabetic.she was started oral antidiabetic drugs tab.Metxl 500 mg, tab. Galvusmet 500mg

10yrs back she was with bilateral lower limb edema and diagnosed with hyperthyroid.

6yrs back she experienced chest pain along with dyspnea at rest and also diagnosed with TVD.

6yrs back she complained of reduced vision in her left eye for which surgery was done.since past three yrs she has also been complaining of right eye vision.

Since past 5-6yrs she has been experiencing tremors of right upper limb and lower limb along with left upper limb. Tremors are more in right upper and lower limb with high amplitude these tremors reduce on doing activity but increase when she is at rest and are absent when she is asleep.

3yrs back her son noticed that she stopped getting involved in conversations and often not responding to the people. No emotions were expressed they also noticed change in her gait.she started walking very slowly.she was taken 5o local hospital for these complaints and diagnosed with Parkinson's disease and was started on tablets tetrebenazine 25 mg OD and tab. Trihexyphenidyl 2mg OD 


H/O Present illness

GCS was 3 and her bilateral pupils were reactive to the light.

Her GRBS was found to be 41mg/dl 

Her other vitals were normal 

She was started on 25D after which her GRBS increased to 161mg/dl and her sensorium improved.

MMSE performed showed a score of only 2/30.she is unable to perform registration,recall or Calculation

Personal history:

Married

Occupation: staying at home

Appetite:lost since 2days

Bowels: irregular

Micturation :reduced from normal output

No known addictions


General examination:

Physical examination:

Pallor is present.      

No icterus

No lymphedenopathy

No cyanosis

System examination

CNS examination:

Power in all her limbs are 5/5
Tone is normal 
Reflexes

           Right Left
B 2+ 2+
T 2+ 2+
S 2+ 2+
K 2+ 2+
A + +
P Withdrawal

Reduced arm swing
Bradykinesia+

Her creatinine is 3.4 and her kidney sizes are reduced. 
HB - 9.8 
Giving a CKD picturePower in all her limbs are 5/5
Tone is normal 
Reflexes

           Right Left
B 2+ 2+
T 2+ 2+
S 2+ 2+
K 2+ 2+
A + +
P Withdrawal

Reduced arm swing
Bradykinesia+

Her creatinine is 3.4 and her kidney sizes are reduced. 
HB - 9.8 
Giving a CKD picturePower in all her limbs are 5/5
Tone is normal 
Reflexes

           Right Left
B 2+ 2+
T 2+ 2+
S 2+ 2+
K 2+ 2+
A + +
P Withdrawal

Reduced arm swing
Bradykinesia+

Her creatinine is 3.4 and her kidney sizes are reduced. 
HB - 9.8 
Giving a CKD picture













Day 3

74yr / F
S : Patient has no fresh complaints.

O :
Pt is c/c/c
Temperature : Afebrile
BP : 140/80mm Hg
PR : 78bpm , regular
GRBS : On 5th 8 PM - 112mg/dl
             On 6th 12AM - 168mg/dl
                          4AM - 130mg/dl
                           8AM - 124mg/dl
CVS : S1 S2 +, no murmur
RS : NVBS + , no crepts
P/A : soft, non tender
SpO2 - 97% at room air
I/O : 1500ml / 1400ml
CNS : Bradykinesia present,
          decreased arm swing
           present
Tone : Rt. Lt
           UL N. N
           LL. N. N
Power : Rt. Lt
           UL. 5/5. 5/5
           LL. 5/5. 5/5
Reflexes : 
                  Rt. Lt
           B :. 2+. 2+
           T :. 2+. 2+
           S :. 2+. 2+
           A :. +. +
           K : 2+. 2+
  

A :
Hypoglycemia secondary to OHA's (resolved) on CKD
? Parkinson's disease
Post CABG 6 years back
K/C/O Hypertension, Diabetes Mellitus II since 25 years
K/C/O Hypothyroid since 10 years
Anemia under evaluation


P : 
1. Head end elevation
2. GRBS charting 6th hourly
3. Intravenous fluids - 1 unit NS at 75ml/hr with 1 Ampule of OPTINEURON
4. Tab MET XL 50mg / PO/ OD
       8AM - X - X
5. Tab THYRONORM 50mg /PO / OD
6. Tab ATORVAS GOLD /PO H/S
     X -X -1
7. Tab NODOSIS 500mg PO/ BD
8. Monitor vitals



Soap notes

Ward Case ,Unit 1
Day 4

74yr / F
S : Patient has no fresh complaints.

O :
Pt is c/c/c
Temperature : Afebrile
BP : 120/80mm Hg
PR : 80bpm , regular
GRBS : On 5th 8 PM - 112mg/dl
             On 6th 12AM - 168mg/dl
                          4AM - 130mg/dl
                           8AM - 124mg/dl
12:30pm --173mg/dl 

6:00pm --199mg/dl 

On 7th 8AM -107 mg/dl 

CVS : S1 S2 +, no murmur
RS : NVBS + , no crepts
P/A : soft, non tender
SpO2 - 97% at room air
I/O : 1500ml / 1400ml
CNS : Bradykinesia present,
          decreased arm swing
           present
Tone : Rt. Lt
           UL N. N
           LL. N. N
Power : Rt. Lt
           UL. 5/5. 5/5
           LL. 5/5. 5/5
Reflexes : 
                  Rt. Lt
           B :. 2+. 2+
           T :. 2+. 2+
           S :. 2+. 2+
           A :. +. +
           K : 2+. 2+
  

A :
Hypoglycemia secondary to OHA's (resolved) on CKD
? Parkinson's disease
Post CABG 6 years back
K/C/O Hypertension, Diabetes Mellitus II since 25 years
K/C/O Hypothyroid since 10 years
Anemia under evaluation


P : 
1. Head end elevation
2. GRBS charting 6th hourly
3. Intravenous fluids - 1 unit NS at 75ml/hr with 1 Ampule of OPTINEURON
4. Tab MET XL 50mg / PO/ OD
       8AM - X - X
5. Tab THYRONORM 50mg /PO / OD
6. Tab ATORVAS GOLD /PO H/S
     X -X -1
7. Tab NODOSIS 500mg PO/ BD
8. Monitor vitals




08/10/21
Soap notes

Ward Case ,Unit 1
Day 5

74yr / F
S : Patient has no fresh complaints.

O :
Pt is c/c/c
Temperature : Afebrile
BP : 130/80mm Hg
PR : 84bpm , regular
GRBS : On 5th 8 PM - 112mg/dl
             On 6th 12AM - 168mg/dl
                          4AM - 130mg/dl
                           8AM - 124mg/dl
12:30pm --173mg/dl 

6:00pm --199mg/dl 

On 7th 8AM -107 mg/dl 
2pm  -- 144mg/dl
8pm -- 150 mg/dl 

8/10/21 8am 166mg/dl

CVS : S1 S2 +, no murmur
RS : NVBS + , no crepts
P/A : soft, non tender
SpO2 - 97% at room air
I/O : 
CNS : Bradykinesia present,
          decreased arm swing
           present
Tone :            Rt.          Lt
           UL        N.          N
           LL.        N.         N
Power :           Rt.        Lt
           UL.        5/5.      5/5
           LL.         5/5.      5/5
Reflexes : 
                  Rt.     Lt
           B :.  2+.    2+
           T :.   2+.    2+
           S :.   2+.    2+
           A :.   +.      +
           K :   2+.     2+
  

A :
Hypoglycemia secondary to OHA's (resolved) on CKD
? Parkinson's disease
Post CABG 6 years back
K/C/O Hypertension, Diabetes Mellitus II since 25 years
K/C/O Hypothyroid since 10 years
Anemia under evaluation


P : 
1. Head end elevation
2. GRBS charting 6th hourly
3. Intravenous fluids - 1 unit NS at 75ml/hr with 1 Ampule of OPTINEURON
4. Tab MET XL 50mg / PO/ OD
       8AM - X - X
5. Tab THYRONORM 50mg /PO / OD
6. Tab ATORVAS GOLD /PO H/S
     X -X -1
7. Tab NODOSIS 500mg PO/ BD
8. Monitor vitals 















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