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.
Chest xray on 20/10/22
CT SCAN ON 13/10/22
MRI ON 18/10/22
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
The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitt.
A 70 year old male resident of Elugupalli came to casualty with complaints of:
History of Fall while bathing 3 days back
Difficulty in walking since 3 days
Slurred speech since 3 days
HOPI:
Pt was apparently asymptomatic 3 days back, then he had history of Fall while bathing on 12/10/22 at evening 4pm he was taking bath by sitting on a rock, suddenly he felt giddiness and fell on the ground on his legs with supporting his left hand to a bucket (no injury to head), and later patient was referred to WellCare hospital at Khammam and later he came to our hospital due to economic issues
Difficulty in walking and slurred speech since 3 days(after fall)
Past history:
K/C/O HTN since 12 yrs
H/O epilepsy 1 episode 12 yrs back
N/K/C/O DM, TB, Asthma, thyroid
Family history: not significant
Personal history:
Patient is a retired constable and then worked as a farmer later stopped working from 10 yrs
He takes mixed diet. His appetite was normal.
Sleep is inadequate from 3 days. Bowel and bladder movements are regular.
Takes Regular Alcohol from 25 yrs: Daily 5-6 units brandy or takes 1-2 bottles toddy, last taken 4 days back
Beedi:1 packet/day from 50 yrs, last taken 4 days back
General examination:
No pallor
No icterus
No cyanosis
No clubbing
No generalized oedema
Vitals:
On admission
Temp: 97F
PR: 82BPM
RR: 24Cycles per min
BP: 140/90 mmhg
Spo2: 95
GRBS: 133 mg/dl
Systemic examination:
CVS examination:
No visible pulsations, scars, engorged veins.
No rise in JVP
Apex beat is felt at 5 ics medial to mid clavicular line.
S1 S2 heard . No murmurs.
Respiratory system examination :
Shape of chest is elliptical, B/L symmetrical.
Trachea is central.
Expansion of chest is symmetrical
Bilateral Airway E +
Per abdomen examination:
No visible pulsations and scars swellings.
Soft, non tender, no organo megaly.
Umbilicus is inverted.
CNS EXAMINATION:
1. HIGHER MENTAL FUNCTIONS:
Patient sitting on the bed and responding to oral commands and questions
Speech-slurring->relevant
Thought: Craving for nicotine
2.CRANIAL NERVES: INTACT
3.MOTOR
Power Right Left
Upper limb 4/5 4/5
lower limb 4/5 4/5
Tone Right Left
Upper limb N N
Lower limb N N
Reflexes: Right Left.
Biceps. - . +++
Triceps. - . ++
Supinator. - . +
Knee. - . ++
Ankle. - . +
4.SENSORY
spinothalamic
crude touch N N
pain N N
Temp N N
post columnar
fine touch N N
vibration N N
position sense 7/10 7/10
Romberg's: Positive
cortical. Stereognosis: N
5.CEREBELLAR:-
Titubation: -
Trunkal ataxia/ Gait ataxia: +
Nystagmus: -
Rebound phenomenon:+
Wide based gait: -
Intentional Tremor: -
Pendular Knee Jerk: -
Tandem walking: +
Coordination
Finger nose test: absent
Heel Knee: absent
Dysdiadokokinesia: +
6.ANS: Normal
7.Meningial signs: NO
8.Spine, cranium, peripheral nerves: Nrml
Chest xray on: 17/10/22
DAY-1
Day2
Day-3:
Diagnosis:1. Cerebellar stroke (leftcerebellar infract)
2. Alcohol withdrawals (deliriumtremens)
3.cardioembolic stroke.
4.Wernickes Korsakoff syndrome
5.alcoholic liver diseas
Treatment:
DAY-1:-
1.T. ESCOPSRIN AV 75mg PO/ODH/S
2.T. CLINIDIPINE 10mg PO/OD
3.T. UDILIV 300 mg PO/BD
4. T. LIBRIUM 10MG PO/BD
5.Inj.CEFTRIAXONE 2MG IV/BD
DAY-2:-
1.T. ESCOPSRIN AV 75mg PO/ODH/S
2.T. CLINIDIPINE 10mg PO/OD
3.T. UDILIV 300 mg PO/BD
4. T. LIBRIUM 10MG PO/BD
5.Inj.CEFTRIAXONE 2MG IV/BD
DAY-3:-
1.T. ESCOPSRIN AV 75mg PO/OD H/S
2.T. CLINIDIPINE 10mg PO/OD
3.T. UDILIV 300 mg PO/BD
4T. LIBRIUM 25MG PO/BD
5.Inj.CEFTRIAXONE 2MG IV/BD
6.T. BENFOTHIAMINE 100mg PO/BD
7.NICOTINE ZOLENGES 2mg BD
DAY-4:-
1.IV Fluids 1-DNS @30ml/hr
2.Inj.CEFTRIAXONE 2G IV/BD
3.6.INJ.THIAMINE 200mg IV/TID 4.T.ESCOPSRIN AV 75mg PO/OD H/S
5.T.CLINIDIPINE 10mg PO/OD
6.T. LIBRIUM 10mg PO/BD
7.T.UDILIV 300 mg PO/BD
8.T.LORAZEPAM 2mg PO/OD(x-x-1)
9.T.QUETIAPINE 12.5mg PO/OD(x-x-1)
10.NICOTINE ZOLENGES 2mg BD(1-x-1)
Day-5:
1.IV Fluids 1-DNS @30ml/hr
2.Inj.CEFTRIAXONE 2G IV/BD
3.INJ.THIAMINE 200mg IV/TID 4.T.ESCOPSRIN AV 75mg PO/OD H/S
5.T.CLINIDIPINE 10mg PO/OD
6.T. LIBRIUM 10mg PO/BD7
7.T.UDILIV 300 mg PO/BD
8.T.LORAZEPAM 2mg PO/OD(x-x-1)
9.T.QUETIAPINE 12.5mg PO/OD(x-x-1)
10.T.PCM 650mg PO/SOS
11.NICOTINE ZOLENGES 2mg SOS
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