Name: K.Sannith Reddy
Roll no. 65
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.
Following is the view of my case :
Cheif complaints:
55 year old male cattle rearer by occupation was brought to the casualty with complaints of Inability to move left sided upper and lower limb since 6 days
Inability to speak since morning
History of presenting illness:
Patient was apparently asymptomatic 6 days back then he developed weakness of left upper and lowerlimb after waking up from sleep
For which he was taken to hospital and diagnosed to have multiple infarcts in frontotemporal areas was treated conservatively
During the stay patient developed an episode of seizure
Lasted for 10 min ?focal seizure , post ictal confusion for 15min
Later patient was discharged
Yesterday night patient had an episode of seizure , focal tonic clonic involving left upperlimb for 5minutes , gained consciousness after 10 minutes
Following which patient was unable to speak patient is conscious and devoloped weakness in left upper limb and lower limb also devoloped urinary incontinence not a/w vomitings
Pasthistory:
- K/C/O Dm since 5 years (under irregular medication)
K/c/o HTN
N/k/c/o asthma ,CAD , TB
Had left index finger amputated
PERSONAL H/O:
APPETITE NORMAL
DIET MIXED
SLEEP: ADEQUATE
BOWEL MOVEMENTS REGULAR AND BLADDER: URINARY INCONTINENCE PRESENT
NO KNOWN ALLERGIES
FAMILY HISTORY: NO RELEVANT FAMILY HISTORY.
GENERAL EXAMINATION:
PT is c/c/c
No palor icterus cyanosis clubbing lymphadenopathy,edema
Vitals @admission:
Temp afebrile
Pr 88bpm
Bp 110/70
Spo2 98%
SYSTEMIC EXAMINATION:
cvs :JVP not raised, s1 s2 heard
RS: BAE + NVBS heard
p/A soft non tender
CNS :
HMF present ,oriented to time ,place and person
Tone : RT LT
UL N. Hyper
LL N. Hyper
POWER
UL 5/5. 2/5
LL 5/5 2/5
REFLEXES: B. T. S. K. A. Plantar
RT. ++. ++. +. ++. + extension
LT. ++. ++. +. ++. +. extension
INVESTIGATION:
PROVISIONAL DIAGNOSIS:
1)CVA WITH ACUTE INFARCT OF RIGHT TEMPORAL AND OCCIPITAL LOBE AND B/L FRONTAL LOBE ( with intraparenchymal hemorrhage)
2)DIABETIC KETOSIS(resolving) SECONDARY TO NON COMPLIANCE
3)WITH TYPE 2 DM SINCE 5YEARS
Treatment:
On 24/12/22
INJ HAI s/c ACC TO GRBS
INJ MANNITOL 300 ML iv TID
INJ LEVIPILL500 MG IV BD
TAB ATORVAS 10 MG PO/HS
On 25/12/22 AMC DAY2
S
no fever spikes
stools not passed
O
pt is c/c/c
temp : afebrile
pr 68bpm
bp: 110/70mm hg
spo2 98% on ra
grbs: 163 mg/dl
GRBS AT
10pm- 160
12am-185
2am-152
4am-149
6am-168
8am-163(12 units HAI given)
cvs :JVP not raised, s1 s2 heard
RS: BAE + NVBS heard
p/A soft non tender
CNS :
HMF present ,oriented to time ,place and person
Tone : RT LT
UL N. Hyper
LL N. Hyper
POWER
UL 5/5. 3/5
LL 5/5 4/5
REFLEXES: B. T. S. K. A. Plantar
RT. ++. ++. +. ++. + extension
LT ++. ++. +. ++. +. extension
A
1)CVA WITH ACUTE INFARCT OF RIGHT TEMPORAL AND OCCIPITAL LOBE AND B/L FRONTAL LOBE ( with intraparenchymal hemorrhage)
2)DIABETIC KETOSIS(resolving) SECONDARY TO NON COMPLIANCE
3)WITH TYPE 2 DM SINCE 5YEARS
RX
INJ HAI s/c ACC TO GRBS
INJ MANNITOL 300 ML iv TID
INJ LEVIPILL500 MG IV BD
TAB ATORVAS 10 MG PO/HS
No comments:
Post a Comment