78 year old female with loss of speech since 1 month
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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.
Chief Complaints:
Inability move limbs and loss of speech since 1 month
HOPI:
Patient was apparently asymptomatic 1 month back then she fell in her daughter’s house and was found unconscious,after the fall she wasn’t able to talk and move.She was taken to a local doctor and was treated for 3 days but the symptoms did not subside. Then she was taken to a private hospital where CT brain was done and was diagnosed as Ischemic stroke .Due to financial issues she was shifted to Government hospital where she was treated well, after that she was able to walk with support and her speech gradually improved and was discharged with medication. After coming home she was not able to take medication properly, her symptoms were getting deteriorated and then she came to our hospital .
No History of Fever ,Cough,Vomting.
No History of Chest pain ,SOB.
Past History:
K/C/O Hypertension since 4 years on tab Amlodipine 5mg Once daily.
Not a known case of DM,CVA,CAD,TB,Asthma,Epilesy,Thyroid disorders.
Daily Routine:
She wakes up at 5 AM in morning,she goes for walking for one hour ,she has breakfast at 8:00 AM then she help her daughter in household work,they have their lunch at 1 :00 PM then she takes rest till 4 PM then she goes for walking for one hour and comes to home, Dinner at 8:00 PM , then goes to sleep by 9:00 PM.
Personal History:
Diet: Mixed
Appetite:Normal
Sleep: adequate
Bowel and bladder: regular.
No addictions.
General physical Examination:
Pallor,Icterus,clubbing,cynosis,lymphadenopathy ,edema absent
VITALS:
TEMP: 98.4F
BP: 100/60 MM/HG
PR: 102 BPM
SPO2: 97%
RR: 20CPM.
CNS EXAMINATION:
Higher mental functions:
Patient is conscious but irritable
Speech :slurred
Language: Can’t understandable
CNS:-
Tone
Right Left
U.L N. Increased
L.L. N. Increased
Power
Right Left
U.L 3/5. 3/5
L.L. 3/5. 3/5
Reflexes
Right left
B ++. ++
T. ++. ++
S. - -
K. ++. ++
A. - -
PLANTAR:- flexor. Extensor
Sensory system: not able to examine as patient in altered sensorium
Signs of Meningeal Irritation:
Neck stiffness: absent
Kernig’s sign :absent
Brudzinski’s sign:absent
PER ABDOMEN-
Soft,non tender,No organomegaly
CVS:
S1 S2 heard , No murmurs
RS:
BAE present,Normal Vesicular Breath Sounds present.
Diagnosis:
Altered sensorium secondary to ?chronic ischaemic stroke,Atrial Fibrillation secondary to ?CAD with Heart failure preserved ejection fraction secondary to CAD.
Investigations:
Hemogram:
HB:12.2 gm/dl
TLC :6900 cells/cu mm
RBC :4.29 million/cu mm
Platelet count:3.0 lakh/cu mm
RFT:
Urea:- 37 mg/dl
Creatinine:-0.9 mg/dl
Sodium:- 140 mEq/L
Potassium:-4.2 mEq/L
Chloride:- 102 mEq/L
LFT:
Total Bilirubin 1.17 mg/dl
Direct Bilirubin 0.86 mg/dl
ALP -150 IU/L
TOTAL PROTEINS:- 7.7 gm/dl
Serology: negative
ECG:
Treatment:
1.INJ NORADRENALINE @4ml/hr IV INFUSION INCREASE OR DECREASE ACCORDING TO MAP
2.INJ MONOCEF 1 gm IV/BD
3. INJ HEPARIN 5000 IU IV/QID
4. TAB ECOSPIRIN AV (75/20) RT /HS
5. INJ AMIODARONE 6mg/ml @ 6.3 ml/hr
6. SYP POTKLOR 15 ml in one glass of water
7. Monitor vitals hourly
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