General Medicine Case Discussion
General Medicine Case Discussion
12/10/2021
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed 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 withcollective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.
E LOG MEDICINE CASE
Roll no : 61
2017 Batch
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 Diagnosis and Treatment Plan.
CHEIF COMPLAINTS :
Patient was alright 9 days back then he complained of altered sensorium,slurring of speech,unable to walk (Weakness) headache .
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 9 days back then he developed headache on the occipital region which is sudden in onset,severe, continuous.radiating to neck for which he taken 3 tablets of Hypertensive medication to relieve from headache at round 2pm,Then he slept and fell down from the bed and he call the attenders for help they noticed he couldn't get up or walk without support dragging his right leg, and not talking properly, he was taken to miryalguda hospital ,where CT brain was done which was normal, he was given IV fluids and stayed there till yesterday morning, as his general condition wasn't improving he was referred here.
Patient also complained chest pain radiating to the left arm and he was taken to the hospital.
ECG showing MI pattern and had CABG , and was on regular medication.
PAST HISTORY:
Patient is a known case of HTN since 4 years.
There is no history of DM,TB, EPILEPSY.
There is a history of blood transfusion during CABG Operation.
FAMILY HISTORY:
Insignificant
PERSONAL HISTORY:
Appetite:Normal
Diet:Mixed
Bowel and bladder habits:regular
Addictions:
Chronic alcoholic 7yrs back now he stopped.
GENERAL EXAMINATION:
Conscious, coherent, co-operative
Moderately built, well nourished.
PROVISIONAL DIAGNOSIS:
Right Hemiparesis with altered sensorium secondary to ? CVA
C/o giddiness with CVA involving ?PCA Territory
S/p CABG ( 6 years back) with k/c/o HTN since 4 years
LFT:
2D ECHO:
S/p CABG
Concentric LVH +. No RWMA
Trivial TR+/AR+. No MR
Sclerotic AV. No AS/MS
EF- 58%. RVSP- 35 mmhg
Good LV Systolic function. Diastolic dysfunction +
No PAH/ PE
IVC size 0.8 cm ( collapsed)
DIAGNOSIS:
1. Acute infarct in both sides of pons and left side of midbrain
2. Post CABG 6 years back
3.K/c/o HTN since 4 years.
COURSE IN THE HOSPITAL:
DAY 1:
IVF NS/RL @ 75 ml /hr
Inj Optinueron in 1 DNS IV/OD
Inj. Ceftrioxone 1g /IV/BD
Inj. Pantop 40 mg IV/OD
Monitor vitals 2 hourly
Input/ output charting.
DAY 2:
Inj Monocef 1 g IV/BD
Inj. Pantop 40 mg IV/OD
Inj Optinueron in 1 DNS IV/OD
Tab. Ecospirin- AV PO/OS
Tab. Clopidogril 75 mg PO/ H/S
Monitor vitals 2 hourly
Input/ output charting
DAY 3:
S:
Pts sensorium has improved.
He is conscious and responding to commands
Slurred speech +
C/o giddiness
O:
PR- 71 bpm, regular
BP- 150 / 90 mmhg
Spo2- 99% at RA
Temp- 98.6F
CNS:
Sensorium improved
Pupils b/l reacting to light
Conjunctival reflex +
Corneal reflex +
Rt Lt
Tone:
UL Decreased N
LL. N N
Power:
UL. 2/5. 5/5
LL. 2/5. 5/5
Reflexes:
B. 2+. 3+
T. 3+. 3+
S. + 3+
A. 2+. 3+
K. +. 2+
P. ^. ^
A:
1. Acute infarct in both sides of pond and left side of midbrain
2. Post CABG 6 years back
3. K/c/o HTN since 4 years
P:
Head end elevation
monitor vitals
strict input/output
ryles tube feeding
Inj. Mannitol 100 ml /IV/TID
Tab.Amlong 10 mg /RT/OD
Tab. Pan 40 mg /RT/ BBF
Tab. Ecosprin gold/ RT/ HS
Inj. Optineuron 1 amp in 100 ml/ IV/OD
Physiotherapy of Rt UL and LL.
DAY 4:
S:
Pts sensorium has improved.
He is conscious and responding to commands
Slurred speech +
Difficulty in swallowing present.
O:
PR- 80 bpm, regular
BP- 160 / 90 mmhg
Spo2- 99% at RA
Temp- 98.4F
CNS:
Sensorium improved
Pupils b/l reacting to light
Conjunctival reflex +
Corneal reflex +
Rt Lt
Tone:
UL . Decreased N
LL. Decreased N
Power:
UL. 2/5. 5/5
LL. 2/5. 5/5
Reflexes:
B. 2+. 3+
T. 3+. 3+
S. + 3+
A. 3+. 3+
K. +. 2+
P. ^. ^
A:
1. Acute infarct in both sides of pond and left side of midbrain
2. Post CABG 6 years back
3. K/c/o HTN since 4 years
P:
Head end elevation
monitor vitals
strict input/output
ryles tube feeding
Inj. Mannitol 100 ml /IV/TID
Inj. Metrogyl 100 ml/IV/BD
Tab.Amlong 5 mg /RT/OD
Tab. Pan 40 mg /RT/ BBF
Tab. Ecosprin gold/ RT/ HS
Inj. Optineuron 1 amp in 100 ml/ IV/OD
Physiotherapy of Rt UL and LL
DAY 6
S:
Pts sensorium has improved.
He is conscious and responding to commands
Slurred speech +
O:
PR- 79bpm, regular
BP- 140 /80 mmhg
Spo2- 98% at RA
Temp- 98.4F
GRBS-124 mg/dl
CVS- S1 S2 + No murmurs
RS- NVBS+ No crepts
CNS:
Sensorium improved
Pupils b/l reacting to light
Conjunctival reflex +
Corneal reflex +
Rt Lt
Tone
UL Decreased N
LL. Decreased N
Power
UL. 3/5. 5/5
LL. 3/5. 5/5
Reflexes
B. 2+. 3+
T. 3+. 3+
S. + 3+
A. +. 2+
K. +. 2+
P. ^. ^
A:
1. Acute infarct in both sides of pons and left side of midbrain
2. Post CABG 6 years back
3. K/c/o HTN since 4 years
P:
1. Head end elevation
2. RT feeds - 50ml free water 2nd hourly , 100ml milk with 2 scoops of Protein powder 4th hourly
3. Tab ECOSPIRIN GOLD / RT/ H/S
4. Inj OPTINEURON 1 Ampule in 100ml / IV / OD
5.Tab.Amlong 5 mg /RT/OD @8AM
6.Physiotherapy of Rt UL and LL
AMC case , Unit 1
55/ M
DAY 7
S:
Pts sensorium has improved.
He is conscious and responding to commands
Slurred speech +
O:
PR- 84bpm, regular
BP- 130 /80 mmhg
Spo2- 98% at RA
Temp- 97.4F
GRBS-103 mg/dl
CVS- S1 S2 + No murmurs
RS- NVBS+ No crepts
I/O 1500/1400 ml
CNS:
Sensorium improved
Pupils b/l reacting to light
Conjunctival reflex +
Corneal reflex +
Rt Lt
Tone
UL Decreased N
LL. Decreased N
Power
UL. 3/5. 5/5
LL. 3/5. 5/5
Reflexes
B. 2+. 3+
T. 3+. 3+
S . + 3+
A. +. 2+
K. +. 2+
P. ^. ^
A:
1. Acute infarct in both sides of pons and left side of midbrain
2. Post CABG 6 years back
3. K/c/o HTN since 4 years
P:
HEAD END ELEVATION
Tab ECOSPIRIN GOLD / RT/ H/S
Inj OPTINEURON 1 Ampule in 100ml / IV / OD
Tab.Amlong 5 mg /RT/OD @8AM
Physiotherapy of Rt UL and LL
DAY 8
S:
Pts sensorium has improved.
He is conscious and responding to commands
Slurred speech +
O:
PR- 84bpm, regular
BP- 130 /80 mmhg
Spo2- 98% at RA
Temp- 97.4F
GRBS-103 mg/dl
CVS- S1 S2 + No murmurs
RS- NVBS+ No crepts
I/O 1500/1400 ml
CNS:
Sensorium improved
Pupils b/l reacting to light
Conjunctival reflex +
Corneal reflex +
Tone Rt Lt
UL Decreased N
LL. Decreased N
Power
UL. 3/5. 5/5
LL. 3/5. 5/5
Reflexes
B. 2+. 3+
T. 3+. 3+
S. + 3+
A. +. 2+
K. +. 2+
P. ^. ^
A:
1. Acute infarct in both sides of pons and left side of midbrain
2. Post CABG 6 years back
3. K/c/o HTN since 4 years
P:
HEAD END ELEVATION
Tab ECOSPIRIN GOLD / RT/ H/S
Tab.Amlong 5 mg /RT/OD @8AM
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