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 :
65 YR OLD MALE WITH C/O VOMITINGS SINCE 2 MONTHS
PT WAS APPARENTLY ASYMPTOMATIC TILL 2YRS. THEN HE COMPLAINED OF GIDDINESS AND WENT TO LOCAL HOSPITAL AND WAS DIAGNOSED WITH HTN. SINCE THEN, HE IS ON AMLODIPINE 5MG
HE HAS VOMITINGS SINCE 2 MONTHS AFTER EATING, NON PROJECTILE, NO FOUL SMELL, NON BLOOD STAINED ,SCANTY WHITISH IN COLOUR
NO H/O FEVER, COUGH, BURNING MICTURITION, CONSTIPATION,HEADACHE
H/O WT LOSS ABOUT 10KG IN LAST 3 MONTHS
HE ALSO COMPLAINTS OF INABILITY TO WALK ON HIS OWN SINCE 2MONTHS ( SINCE VOMITINGS STARTED)
BEFORE 2 MONTHS HE USED TO WALK ON HIS OWN AND HE IS FARMER BY OCCUPATION
PAST H/O:
K/C/O HTN SINCE 2 YRS UNDER REGULAR MEDICATION (AMLO 5)
NOT K/C/O DM, CAD, CVA, EPILEPSY, TB, ASTHMA
PERSONAL H/O:
APPETITE NORMAL
DIET MIXED
SLEEP: ADEQUATE
BOWEL AND BLADDER: REGULAR
NO KNOWN ALLERGIES
FAMILY HISTORY: NOT SIGNIFICANT
GENERAL EXAMINATION:
PATIENT IS CONSCIOUS ,COHERENT AND COOPERATIVE.
ORIENTED TO PLACE, PERSON BUT NOT TIME
NO PALOR ,ICTERUS, CYANOSIS, LYMPHADENOPATHY, EDEMA
VITALS AT ADMISSION:
BP: 110/80MMHG
PR: 88BPM
RR: 18CPM
SPO2: 98%AT RA
TEMP 98°F
SYSTEMIC EXAMINATION:
CVS: S1,S2 HEARD
RS: BAE+
CNS:
HIGHER MOTOR FUNCTIONS:
Consciousness - conscious
Oriented time x place ✓ person ✓
Speech and language - n
Memory
- immediate - retention decreased
Recall decreased
recent decreased
remote ✓
Delusions and hallucinations absent
MMSE SCORE 25/30
CRANIAL NERVES RIGHT LEFT
CN 1 Normal
CN 2. Field of vision ⬇️. ⬇️
Colour vision. N. N
CN 3 4 6 Extra ocular movements. N. ⬇️
Pupil size NSRL. NSRL
Direct, Indirect reflex N. N.
Accomodation. N. N
Ptosis absent. Absent
Nystagmus. absent. Present
CN 5. Sensory and motor reflexes normal
Jaw jerk Absent
CN 7 ,8 ,9,10,11,12. Normal on both sides
MOTOR: TONE NORMAL, POWER IN BOTH UL IS 5/5, IN BOTH LL IS 4+/5
CEREBELLAR SIGNS:
ATAXIA - SWAYING TO LEFT
NYSTAGMUS PRESENT IN LEFT EYE TO THE LEFT
NO DYSARTHRIA
NO HYPOTONIA
TITUBATION ABSENT
NO INTENTION TREMOR
PENDULAR KNEE JERK ABSENT
UL CORORDINATION
FINGER NOSE TEST POSITIVE
FINGER FINGER TEST POSITIVE
(NO COORDINATION )
LL. HEEL KNEE TEST
Rt. Lt
++. -
RT. LT
DYSDIADOKINESIA +. +
MOTOR: TONE NORMAL, POWER IN BOTH UL IS 5/5, IN BOTH LL IS 4+/5
REFLEXES ON BOTH SIDES:
B ++
T ++
S +
K +
A +
P F
P/A: SOFT, NON TENDER
INVESTIGATIONS:
HB: 14.9
TLC: 10,300
PLT: 3.56
RBC: 5.33
NA+: 130
K+: 3.9
Cl- 94
CA++: 0.93
LFT:
TB: 2.38
DB: 0.7
AST: 24
ALT: 13
TP: 6.9
ALB: 4.2
A:G: 1.53
SR CREAT: 1.3
BLOOD UREA: 56
SR OSM: 260
RBS: 90
BLOOD GRP: O+
USG ABDOMEN : NO SONOLOGICAL ABNORMALITY
Chest xray :
Xray abdomen erect :
XRay of knee joint :
MRI BRAIN :
44x41x42mm Peripherally enhancing thick irregular wall intra axial lesion in left cerebellar hemisphere extending into vermis
Lesion is causing compression and displacement of 4rth ventricle to contralateral side with resultant mild dilatation of lateral and 3rd ventricle suggestive of acute hydrocephalus
Periventricular hyperintensity suggestive of transependymal sepage of CSF
PROVISIONAL DIAGNOSIS:
1.Chronic vomitings since 2 months secondary to ?lt Cerebellar lesion compressing 4th ventricle ? Acute hydrocephalus secondary Mets? Primary brain malignancy
2.k/c/o htn since 2 yrs with b/l OA knee grade 4, lt more than rt
TREATMENT:
17/12/22
INJ ZOFER 4MG IV TID
INJ PAN 80MG IN 50ML NS CONT IV INFUSION
IVF AT 75ML/HR
ORS 1 PACKET IN GLASS OF WATER IN SIPS
GRBS 4TH HRLY
18/12/22
INJ OPTINEURON 1AMP +100 ML NS IV OD
INJ ZOFER 4MG IV TID
TAB PAN D 40/30 PO/BD
IVF AT 75ML/HR
ORS 1 PACKET IN GLASS OF WATER IN SIPS
PROCTOLYTIC ENEMA
GRBS 4TH HRLY
19/12/22
INJ OPTINEURON 1AMP +100 ML NS IV OD
INJ ZOFER 4MG IV TID
TAB PAN D 40/30 PO/BD
IVF AT 75ML/HR
ORS 1 PACKET IN GLASS OF WATER IN SIPS
TAB AMLONG 5MG PO OD
GRBS, BP 4TH HRLY
20/12/22
INJ OPTINEURON 1AMP +100 ML NS IV OD
INJ ZOFER 4MG IV TID
TAB PAN D 40/30 PO/BD
IVF AT 30ML/HR
TAB SHELCAL CT PO OD
TAB JOINTACE PO OD
D2 INJ LEVERA 500MG IV BD
D2 INJ DEXA 8MG IV TID
GRBS, BP 4TH HRLY
No comments:
Post a Comment