Self reflective writing on their medical student career

 Self reflective writing on their medical student career 

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 patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

This E blog also reflects my patient-centered online learning portfolio and your valuable input in the comment box is welcome.

BLOG LINK :-

https://kattaphanikeerthanarollno72.blogspot.com/2023/09/a-70-year-old-male-presented-to-opd.html

It was my first Casuality duty day, I came across my 1 st case, A 70 year old was coming in a stretcher 

with chief complaints of weakness in both upper limb and lower limb Since 1/2/23 evening 

Slurring of speech since 1/2/23 evening.

And I have no clue what to do 

Then I decided to think what can be done to help him and started working on him 

I started taking proper history with the help of his son who was co operative 

And went through the history 

Patient was apparently asymptomatic till yesterday then he started having pain in both lower limb followed by weakness in both upper limb and lower limb and slurring of speech 

No C/o chest pain,palpitations,sob

No c/o orthopnea,PND 

H/o thorn prick to left LL followed by cellulitis of left ll for which fasciotomy was done 1.year back 

Past history- Not a K/c/o

Htn, DM, TB, Epilepsy,Asthma 

And examined the patient in the Casuality to find 

GENERAL EXAMINATION:- 

THE PATIENT IS CONSCIOUS COHERENT AND COOPERATIVE 

NO PALLOR ; ICTERUS; CLUBBING; CYANOSIS; ODEMA ; LYMPHADENOPATHY

TEMPERATURE:- 98.8 F 

PR:92 bpm

BP:140/100 mm Hg

RR-16 cpm

Grbs- 132 mg/dl 

SYSTEMATIC EXAMINATIONS:-

CNS Examination:

Higher mental functions:

Patient is conscious oriented to time place and person 

Speech and language :slurring of speech present 

Memory :intact( Recent,Immediate,Remote)

Hallucinations -absent

Sensory system - Normal 

Motor system-          Right.         Left. 

Tone- Upper limb     Hypo          Hypo

            Lower limb     Hypo           Hypo 

Power- Upper limb     2/5               2/5

              Lower limb      2/5               2/5 

Reflexes- Biceps.        Absent        Absent 

                 Triceps          2 +               2+

                 Supinator.      Absent        Absent 

                Knee                 2+                2+

                Ankle.                1+.                1+

                 Plantar           Mute             Mute 

Investigations 

Provisional diagnosis-

Hypokalemic periodic paralysis 

  

 These are Investigations I ordered for patient - 

2/9/23 

Hemogram 

Hb- 19.3 

TLC - 25,900 

PLT count- 2.95 

PCV - 55.1 

Mcv - 83.9 

Mch- 29.4 

CUE- 

Sugars - nil 

Alb - 3-4 

Pus cells - 3-4 

Epithelial cells - 2-3 

RFT- 

Blood urea - 53 

S.creat- 1.7 

Na+ 130 

K+ # 2.6 

Cl - 100 

S. Magnesium- 1.9 

LFT - 

Tb- 2.25 

Db - 0.48 

Sgot- 29 

Sgpt- 16 

ALP - 211 

TP - 7.7 

Alb - 1.16 

ABG

PH - 7.351

3/9/23 

Hb - 16.4 

Tlc- 20000 

DLC - 2.27 

Rft 

S. Na + 132 

S. K+ 2.7 

S. Cl - 106 

 4/9/23 

Na+ 136

K+ 1.8

Ca+  104 

My management plan 

P:

1) IV NS @50 ml/hr 

2) Syp. Potklor 15 ml in 1 glass of water PO/TID 

3) T. ECOSPRIN -AV 75/10 Po/ Hs

4) Strict I/o charting 

5)Monitor vitals every 2nd hrly

6)T.Telma 40 mg Po /OD 

7)Inj. Ceftrioxone 1gm IV/ Bd

PAJR DISCUSSION:- 

It was a fruitful discussion 

https://chat.whatsapp.com/Jc43jR1klLF7ovLA3oagvU

[05/09/23, 8:54:43 AM] ~ Keerthi Madireddi: @919381040824 update soap notes and also draw a graph showing the potassium values and intervention done.

[05/09/23, 8:55:52 AM] Keerthana: Ok mam

[05/09/23, 9:02:57 AM] ~ Keerthi Madireddi: @919381040824 please make me and hod sir as admin

[05/09/23, 9:04:03 AM] ~ Keerthi Madireddi: ☝🏻

[05/09/23, 9:46:51 AM] Rakesh Biswas Sir Hod Medicine: Mention duration in the title

[05/09/23, 10:40:57 AM] Keerthana: Date-5/9/23

Ward-ICU  Bed 5 

Unit 6 

Date of admission 2/9/23

S - 

C/o weakness in both upper and lower limb,

C/o slurring of speech since 4 days 

O - 

On examination 

Patient is conscious coherent and cooperative. 

No Pallor, Icterus, cyanosis, clubbing, lymphadenopathy, edema.

Vitals:

Temp: 98.6 F

PR: 72 bpm

BP:120 /80 mm hg

RR: 25 cpm 

CVS: S1 ,S2 heard

RS:B/L AE present , NVBS +. No added sounds

P/A:Soft, non tender, no organomegaly.

No rigidity,Guarding.

CNS:                  Rt                  Lt 

                                           

Tone      U/L     Hyper            Hyper 

               L/L     Normal       Normal 

 Power- U/L    4-/5              4-/5

              L/L     4-/5              4/5

Reflexes- B       3+                 3+

                 T       3+                  3+

                 S.      3+.                3+

                Knee   3+              3+

                Ankle. 1+.                1+

               Plantar  Mute         Mute 

   

A:? Hypokalemic periodic paralysis. denovo htn 

 P:

1) IV NS @50 ml/hr 

2) Syp. Potklor 15 ml in 1 glass of water PO/TID 

3) T. ECOSPRIN -AV 75/10 Po/ Hs

4) Strict I/o charting 

5)Monitor vitals every 2nd hrly

6)T.Telma 40 mg Po /OD 

7)Inj. Ceftrioxone 1gm IV/ Bd

05/09/23, 10:42:50 AM] Rakesh Biswas Sir Hod Medicine: Why ceftriaxone? @919908159666

[05/09/23, 10:44:15 AM] Rakesh Biswas Sir Hod Medicine: What about the leg ulcer? Why is that not mentioned? Cause and duration of the ulcer?

[05/09/23, 10:45:41 AM] Keerthana: Will mention it sir

[05/09/23, 10:53:17 AM] Keerthana: Sir the ulcer of the leg was his past illness( a year ago) for which he was treated with regular debridement and dressing and the ulcer is healed now. There nothing to be done for the ulcer as it healed.only thing can be done is graft placement for the purpose of cosmetic purpose. 

As of now major issue is his hypokalemia causing weakness of limbs

[05/09/23, 11:01:22 AM] Narsimha Sir Gm Pgy2: What about Slurring of Speech during admission  ??

[05/09/23, 11:02:17 AM] Narsimha Sir Gm Pgy2: What was the Reason for his Chronic Ulcer ? Is it Diabetes ?? What about his FBS ; PPBS & HbA1c

[05/09/23, 11:03:19 AM] Keerthana: Sir , ceftriaxone⁩ is started because the counts of the patient is raised I.e., 16200 and as it is 3 rd generation cephalosporin it shows it’s activity on both gram positive and negative bacteria so it was started!

[05/09/23, 11:08:24 AM] Narsimha Sir Gm Pgy2: Can Hypokalemia Present with Slurring of Speech ??

[05/09/23, 11:08:50 AM] Narsimha Sir Gm Pgy2: Or it was due to his C2H5OH ??

[05/09/23, 11:23:23 AM] Rakesh Biswas Sir Hod Medicine: What bacteria would be raising the counts? 

Is it a good idea to treat the counts and not the patient?

[05/09/23, 11:26:39 AM] Keerthana: Intially the Counts were raised sir ....But Clinically he was good ...But Since Yesterday He was having Fever Spikes & We didn't Localise the cause yet So We thought of Starting him on Emperical antibiotics. But did not start yet.

My learning points:- 

I learned level 2 and level 3 stuff from this patient 

Mainly on how is Hypokalemia is caused 

How to treat Hypokalemia 

And also different tests to rule of other causes

https://recapem.com/hypokalemia-emergency-management/

SWOT analysis (Strengths, Weaknesses, Opportunities, Threats) of the patient's case:

Strengths:

1. He has a supportive family who provides financial stability and assistance.

2. He is able to sleep better with the use of medication given for his hypokalemia 

Weaknesses:

1. The tone of the patient was hypotonic .

2. Patients slurring of speech didn’t improve 

3.on continuous monitoring but still his condition is not getting better for first 3-4 days 

Opportunities:

1. Further evaluation and neurologist referral provide an opportunity for a comprehensive assessment and management of her condition.

Threats :- 

Recurrence of the condition may occur.