General medicine case- 4

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.

Date of admission: 23/09/2021


A 85 year-old man, who is a farm worker by occupation, presented to the hospital with complains of

- Weakness of left upperlimb and lowerlimb since 20 days

-Deviation of mouth towards left side since 20 days

- Difficulty in swallowing since 20 days.


History of present illness:

The patient was apparently asymptomatic 20 days back then had sudden weakness in left upperlimb and lower limb one morning.

He couldn't walk and also noticed difficulty in swallowing.

He was taken to the local hospital and was later referred to Kamineni for further treatment.


Past history:

The patient is a known case of hypertension since 3 years.

Not a known case of Diabetes mellitus, Asthma, Tuberculosis, Epilepsy.


Personal history: 

The patient has a mixed diet.

Has a loss of appetite since 20 days.

Bowel and bladder movements are normal.

The patient is a chronic smoker(4-5 chutta/day)and alcoholic since 20 years.

Has stopped drinking and smoking 2 months ago.


Treatment history: 

The patient is not allergic to any known drugs.


General examination:

The patient is conscious, coherent and cooperative

 Pallor- Yes

Cyanosis- No

Lymphadenopathy- No 

Clubbing of fingers- No

Pedal edema- No





Vitals:

Temperature- Afebrile

Pulse rate- 100 bpm

Blood pressure- 140/90 mmhg

Respiratory rate- 22 cycles per min


Systemic examination:

CVS- S1 and S2 heard 


Respiratory system:

NVBS present 


CNS 

Conscious 

Speech - normal

No signs of meningeal irritation

Tone- Increased in left side.

Investigations: 










Diagnosis:
CVA with left UMN Palsy with acute infarct 
in Right Parietal lobe and Frontoparietal lobe.


Treatment:

RT FEEDS 100 ML MILK - 2ND HOURLY , 100ML HOURLY

2) INJ PAN 40 MG /IV/OD

3) INJ OPTINEURON 1 AMP IN 100 ML NS /IV/OVER 30 MIN

4)TAB ASPIRIN 100 MG RT/OD

5)TAB CLOPIDOGREL 75 MG RT /OD/H/S

6) TAB ATORVASTATIN 40 MG /RT/OD/HS




Comments

Post a Comment

Popular posts from this blog

General medicine case-6

Image
 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome. Date of admission: 15/10/21 A 50 year old female came to the OPD with chief complaints of lower backache, decreased urine output, shortness of breath and fever since 4 days. History of present illness: The patient was apparently asymptomatic 4 days back when she noticed a pain in the lower back and decreased urine output and shortness of breath. History of past illness: The patient is a known case of hypertension since 7 years. Not a known case of diabetes,asthma, epilepsy, tuber
Read more

Prefinal assessment

Image
 1) Define heart failure. Etiology and clinical features of heart failure? How do we diagnose heart failure clinically. Physical examination and various modalities used in diagnosis of heart failure. Write a brief note of treatment of heart failure. 2) Define cirrhosis of liver. Etiopathogenesis of cirrhosis. Write a brief note on clinical features, diagnosis and treatment of cirrhosis of liver. 3) Elaborate on clinical features and diagnostic modalities in diagnosis of renal calculi. 4) Etiology of pleural effusion. Diagnostic criteria of pleural effusion. 5) Diagnosis and treatment of dengue fever. 6) Clinical features and diagnosis of peptic ulcer disease.  7)Treatment of acute pyelonephritis. 8) Treatment of abdominal tuberculosis. 9) Etiology and treatment of pneumonia. 10) Complications of dialysis. 11) Ascitic fluid analysis. 12) Proton pump inhibitors. 13) Afterload reducing agents in heart failure. 14) Treatment of urinary tract infection. 15) Differential diagnosis of fever w
Read more

GM Case history-1

Image
 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here, we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.    Date of admission: 09-08-2021 A 56- year- old woman presented to the OPD with chief complaints of fever, decreased urine output since 3 months and  breathlessness from the past 3 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 5 years back, then had fever which was insidious and associated with chills, vomiting and pain in the loin for which she went to outside hospital where she was diagnosed with kidney disease, from then she was on medication. 7 months back she stopped medication for 1 month, then after that she developed shortness of breath for which she went to a local
Read more