History of presenting illness

Question

Bogalech Tadesse is 18 yrs old female client presented with muscle tremor, confusion, epigastric pain, sever diaphoresis. Shewas well and performing NDA before 5 hrs.
History of past illness
Two years back she was admitted in ewa hospital for severe malaria.
Personal history
She sometimes drinks alcohol for last five years but she did not have habit of chewing chat.
Social and family History
She is notmarried but have boyfriend and living with her family. Both parents are alive. Her parents live in rural area.
Review of systems
HEENT: has headache, no blurred vision
lGS: no swelling and enlargement
Respiratory: no cough and she has shortness of breath
CV: palpitation
GIT: have nausea, vomiting, loss of appetite, epigastric pain
GUS: NAD
MSS: involuntary movement of both lower and upper extremities
Skin: dry oral mucosa
CNS: irritable and confused
Discussion Questions
1. Explain any new problem you identify? Why?

Answer 1

Based on the provided history and clinical presentation of Bogalech Tadesse, several new problems can be identified, particularly around her acute symptoms and medical history.

New Problem Identification

1. Acute Confusion and Neurological Symptoms: Bogalech is experiencing confusion and involuntary movements in both her upper and lower extremities, which can indicate a neurological issue. The combination of muscle tremors, confusion, and irritability suggests possible central nervous system (CNS) involvement, which could be due to a metabolic derangement, infection, or substance-related issue.

2. Severe Diaphoresis and Epigastric Pain: The severe sweating (diaphoresis) and epigastric pain, along with nausea and vomiting, lead to concerns about a severe systemic infection, a potential withdrawal from alcohol, or an acute abdomen, among other possibilities.

3. Respiratory Distress: The reported shortness of breath can indicate several conditions, including anxiety, a possible metabolic imbalance (e.g., acidosis), or respiratory issues secondary to her neurological involvement.

Why This is Concerning

• Neurological symptoms: The confusion and involuntary movements could be indicative of several serious conditions, including seizures, metabolic disturbances (like hypoglycemia or hyponatremia), or toxic ingestion (due to alcohol or other substances).
• Gastrointestinal symptoms: Nausea, vomiting, and epigastric pain may indicate an underlying gastrointestinal pathology or a reaction to stress, toxins, or withdrawal.
• Cardiovascular signs: Palpitations in conjunction with these symptoms may suggest an anxiety response, but they could also be related to metabolic derangements or substance withdrawal.
• Dehydration signs: The dry oral mucosa indicates possible dehydration, which can compound her symptoms and suggest inadequate fluid intake or excessive loss due to sweating.

Conclusion

Bogalech has multiple concerning presentations that indicate a need for urgent evaluation and management. The neurological symptoms, in particular, require immediate consideration of possible causes such as electrolyte imbalances, infections, or substance abuse effects, given her social history. Further diagnostic workup, including laboratory tests (electrolytes, glucose, complete blood count, liver function tests), imaging studies, and possibly a toxicology screen, is crucial to identify the underlying cause of her acute symptoms.