Pravallika Gade , MBBS 3rd semester
Roll no: 41
Under the guidance of Dr. Sai Vittal sir (Intern)
This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.
Here we discuss our individual patient problems through a series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-log also reflects my patient centered online learning portfolio.
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 a diagnosis and treatment plan.
CASE SCENARIO:
A 55 year old male patient presented to the casuality on (when) with chief complaints of weakness of movements of left upper and lower limbs, deviation of mouth to right side, slurring of speech, difficulty in swallowing , drooling from left side of mouth and involuntary micturition.
HISTORY OF PRESENT ILLNESS:
Previous visits to any hospital with same illness??
No H/O of involuntary movements, fasciculations an sensory loss.
PAST HISTORY:
K/C/O DM Type II since 9 months
Denovo HTN
TREATMENT HISTORY:
On medication for DM
Tab. Metformin 500 mg OD
Glimi 2 mg OD
Voglibose 0.2 mg OD
SURGICAL HISTORY:
No relevant history
PERSONAL HISTORY:
Married
Occupation: Farmer
Diet: Mixed , Non vegetarian
Appetite: Decreased
Sleep: Adequate
Bowels: Irregular
Allergies: No
Addictions: No
FAMILY HISTORY:
No H/O similar complaints in the family
PHYSICAL EXAMINATION:
Patient is conscious and coherent
Moderate built and moderately nourished
Well oriented to time, place and person.
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
VITALS:
Temperature: Afebrile
Pulse rate:102 bpm/min
BP:140/100 mm Hg
Respiratory rate: 20cpm/min
SpO2: 96%
SYSTEMIC EXAMINATION:
CVS EXAMINATION:
Thrills: No
Cardiac sounds: S1 , S2
Cardiac murmurs: No
RESPIRATORY SYSTEM:
Dyspnoea: No
Wheeze: No
Position of trachea: Central
Breath sounds: Vesicular
Adventitious sounds : No
ABDOMEN EXAMINATION:
Shape of abdomen: Scaphoid
Tenderness : No
Palpable mass: No
Hernial orifices: No
Free fluid: No
Bruits: No
Liver: Not palpable
Spleen: Not palpable
Bowel sounds: Yes
CNS EXAMINATION:
Level of consciousness: Conscious and alert
Speech: Slurred
Signs of meningeal irritation:
Neck stiffness: No
Kerning’s sign: No
Cranial nerves: Deviation of mouth towards right side
Motor system:
Power R L
UL 5/5 0/5
LL 5/5 0/5
Tone R L
UL Normal Decreased
LL Normal Decreased
Reflexes
Biceps Triceps Supinator Knee Ankle
RIGHT + + + ++ ++
LEFT + + + ++ ++
Plantars : Extensor
Cerebral Signs:
Finger nose In-coordination : Yes (+) on right side
Knee Heel IN-Coordination: Yes (+) on right side
INVESTIGATIONS:
Haemogram, CUE. ECG, CXR- PA view ,RFT , LFT, HBA1C , FBS , PLBS
HAEMOGRAM
PROVISIONAL DIAGNOSIS:
HEMIPLEGIA secondary to ACUTE INFARCT in B/L corona radiata, left side caudate nucleus and right frontal lobe
PRE- RENAL AKI
K/c/o DM II since 9 months
TREATMENT:
IV fluids NS and RL @ 100 ml/hr
Tab. ECOSPRIN 150 mg PO/OD
Tab. CLOPITAB 75 mg PO/OD
Tab. ATORVAS 20 mg PO/HS
Tab. PANTOP 40 mg PO/OP
Tab. Tab. Metformin 500 mg + Glimi 2 mg + Voglibose 0.2 mg PO/OD
Physiotherapy of left upper and lower limbs
I/O charting
BP/PR/TEMP monitoring
Thank you Dr.Rakesh Biswas sir for this opportunity.
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