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Case 1



Hi, I am V.Nikhitha , 5th semester 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 the piece of work whatsoever.


29 year old male patient . Daily labour by occupation , resident of Bhongir came with 

Chief complaints 

Pain abdomen 10 days 
Vomitings 10 days 
Involuntary movements of left upper limb  1 week 

History of present illness  
Patient was apparently asymptomatic 10 days ago then he developed pain abdomen 10 days ago which was sudden onset in epigastric region , sharp which is radiating towards back , aggrevating on taking foods.
• H/o 2 episodes of vomiting which is non bilious non blood tinged , non projectile water as content .
• H/o seizure , involuntary movemnt of the left upper limb a/w Deviation of mouth to right side  uprolling of eyes , drooling of saliva 
H/o Loss of conciousness for almost 15 mins and regained his conciousness.
H/o Slurring of speech 
H/o Memory loss 
No H/o Trauma ,
No H/o Neck stiffness , 
No H/o Fever ,
No H/o weakness
No H/o Loose stools involuntary micturation or defecation 

History of past illness 

Patient had pain abdomen and 2 episodes of vomiting for which he was admitted in local hospital  he had an 1 episode of involuntary movemnents , 
- history of Left shoulder disslocation during his seizures.
- N/k/c/o HTN, DM ,TB,BA,CVA,CAD, Thyroid disorders .

Surgical History 
Pt underwent Surgery for Hernia

Drug allergies 
Not significant

Family History 
No H/o seizures in family 

Personal History 
Diet - Mixed 
Appetite - Decreased 
Sleep - Decreased 
Bladder & Bowels - Irregular 
Addictions - Alcoholic since 10 years Whiskey 500 ml daily . and experience palpitations tremors in its absence for 3 days

General examination 

Patient is concious , coherent , cooperative to time place person 
Pt is Moderately built & moderately nourished 

No Pallor - 
No icterus 
No cyanosis 
No lymphadenopathy 
No koilonychia
No pedal oedema 

Vitals 

Temperature  afebrile 
Bp - 130/90 mmhg 
RR - 20 cpma
HR - 93 bpm
Spo2 - 99% on RA

Height 160 cms
Weight 60kgs 

Systemic examination 

CENTRAL NERVOUS SYSTEM

Pt is C/C/C 

HMF - Intact 

Speech & language – Normal 

Memory can recall

No Signs of Meningeal irritation 

Motor and sensory system – Normal 

Reflexes – Normal 

Cranial Nerves – Intact 

Gait – Normal

Cerebellum – Normal  

GCS Score – 15/15

CRANIAL NERVE 

OLFACTORY -  NORMAL (SMELL) 

OPTIC - Normal 

OCCULOMOTOR - Normal

TROCHLEAR  Normal

TRIGEMINAL Normal

ABDUCENS Normal

FACIAL NERVE  Normal

VESTIBULOCOCHLEAR Normal

GLOSSOPHARYNGEAL Normal

VAGUS - Gag reflex present 

SPINAL ACCESSORY Normal shrugging shoulders

HYPOGLOSSAL Normal ( Not deviated )

MOTOR SYSTEM

Bulk - 




                         Right.                Left 

Tone      UL     5/5           Unable to perform due 
                                               to his pain 
              LL.     5/5                    5/5 

Power.   UL       5/5.                    Unable to                                                              perform due 
                                                   to his pain 
               LL       5/5                      5/5 

REFLEXES

Corneal - N
Conjuctival - N
Pharyngeal - N
Palatal -N
Abdominal -N
Cremasteric - N

DEEP TENDON REFLEX

Jaw Jerk - N
Biceps - N
Triceps - N
Supinator - N
Knee jerk - N
Ankle jerk- N
Clonus - absent



Position sense:      

                                   Right             Left

Upper Limb              10/10           unable to                                                            perform due to                                                         his pain 

Lower Limb              10/10              10/10

-Graphaesthesia-Postive

-Stereognosis-Positive

Cerebellar signs:

-Titubation:absent

-Nystagmus:absent

-Dysarthria:absent

-Hypotonia:absent

-Intention tremor:absent

-Coordination

a.Finger Nose test: Normal 

b.Heel Knee test: Normal

c. Dysdiadokokinesia: Negative( able to perform rapid alternative movements)


Signs of Meningeal Irritation:

Neck stiffness: absent 

Kernig’s sign :absent

Brudzinski’s sign:absent

CARDIOVASCULAR SYSTEM

INSPECTION 

Chest is elliptical shaped, bilaterally symmetrical.

Trachea appears to be central 

Movements are equal bilaterally

JVP:Raised 

No Visible epigastric pulsations 

 No scars or sinuses

PALPATION

All the inspectory findings are confirmed 

Trachea is central 

Apical impulse felt at 5th intercostal space lateral to midclavicular line.

AUSCULTATION 

S1 S2 heard no murmurs 

RESPIRATORY SYSTEM 

INSPECTION

Chest is elliptical shaped,

bilateral symmetrical.

Trachea is central 

Movements are equal bilaterally

No Visible epigastric pulsations 

No scars or sinuses

Apical impulse not seen

PALPATION

All inspectory findings are confirmed: Trachea is central, movements equal bilaterally.

 Antero-posterior diameter of chest >Transverse diameter of chest

Apex beat felt in 6th intercostal space lateral to midclavicular line 

PERCUSSION

Resonant note heard in all  areas bilaterally

AUSCULTATION

Bilateral air entry present – Normal vesicular breath sounds heard


PER ABDOMEN

INSPECTION 

Shape of abdomen appears to be scaphoid

No Visible epigastric palpations 

No engorged veins sinus scars

PALPATION 

All inspectory findings conformed

Tenderness + 

Palpable mass near left Hypochondrium

No organomegaly

PERCUSSION 

Tympanic note heard all quadrants abdomen

AUSCULTATION

Bowel sounds heard in RIF


CLINICAL IMAGES 









Provisional Diagnosis 

? Acute pancreatitis 
? Alcoholic gastritis 

DIAGNOSIS

Focal seizures 





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