Sunday, 25 December 2022

A CASE OF 55 YEAR OLD

 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 

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


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

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