This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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 diagnosis and treatment plan.
CASE:
A 72 year old male patient from Basireddypally, goldsmith by occupation presented to the casualty with chief complaints of involuntary movements of left upper and lower limbs 3 days back.
HOPI:
Patient was apparently asymptomatic 7 months back then he had numbness and tingling sensation in the left upper limb, they went to a RMP he referred the patient to a hospital, by the time they reached the hospital he was having paralysis of left upper and lower limbs. He was admitted in ICU, and he was found to have GRBS of 480mg/dl, they performed scanning and diagnosed as to have stroke, they gave him an injection after which he started to have eye twitching which has stopped after giving him another injection. He was on antiepileptics, antiplatelets, statins. He was advised for physiotherapy and able to walk with the help of a stick after 1month but he can't still move his left upper limb.
3days back on 25-7-2022 morning 4am his daughter observed that he is snoring very loudly, they called an RMP by the he came he started to have involuntary movements of left upper and lower limbs lasted for 5 min, rmp gave him an injection after another 5 min he had another seizure episode, the patient is taken to nearby hospital and had 2 more episodes the same day, the mouth is deviated to the right side with d dribbling of saliva and not associated with urinary incontinence, tongue bite. He is not responding to the attenders.
Past history:
He is known case of CVA.
Known case of diabetic on Metformin and Glimiperide from 7 months.
Not a known case of Hypertension, asthma, Tuberculosis, CAD.
Personal history:
Diet-mixed
Appetite-normal
Sleep- sleeps after having a pill
Bowel and bladder movements-regular
He is a smoker since 50 years and non-alcoholic.
Family history: No relevant family history.
General examination:
Patient is conscious, non coherant.
Poorly built and moderately nourished .
Pallor-absent
Icterus-absent
Clubbing- absent
Cyanosis-absent
Generalised lymphadenopathy-absent
Pedal edema-absent
Vitals:
Temperature-99.2degree F
Pulse rate-70bpm
Respiratory rate-20cpm
Blood pressure-130/80mmhg
Spo2-97%
GRBS-357mg/dl
Systemic examination:
CNS:
Higher mental functions:
CVS: S1, S2 heard, no murmurs heard.
Respiratory system:Barrel shaped chest, Bilateral air entry-present, normal vesicular breath sounds-heard, no adventitious sounds heard.
Abdomen: soft and non tender, no Hepatomegaly and spleen is not palpable.
Provisional diagnosis:
Focal tonic clonic seizure (Stroke related epilepsy).
Investigations:
CT scan of brain: on 7-12-2021
MRI Brain :
ECG:
2d echo heart:
Treatment:
Inj. PIPTAZ 2.25gm I.v B.D
Inj. LEVIPIL 1gm I.v B.D
Tab. UDILIN 300mg P.o B.D
Tab. ATENOLOL 50mg P.o O.D
Tab. ECOSPRIN 10mg P.o O.D
Syp. HEPAMERZ 15ml P.o TID
Syp. POTCHLOR 15ml P.o TID.
Syp. LACTULOSE 10ml p.o h/s
Tab. FEBUXOSTAT 40mg P.o h/s
Refer to our senior blog for the findings at the time of admission:
https://deepikaraga97.blogspot.com/2022/07/75-year-old-male-shopkeeper-by.html?m=1
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