75F WITH ALTERED SENSORIUM

Hello all this is G Pranay kumar rao,a eighth semester student.This E Log depicts the patient centered approach to learning

This is an 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.

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.

75 yr old female came to opd with chief complaints of altered sensorium since yesterday

History of present illness:-

Patient was apparently normal until 3pm yesterday (19/10/2023). 

She then became altered since 3pm yesterday and started speaking random words, not answering revelantly and without deviation of mouth with weakness of right upper limb and right lower limb.

Associated with involuntary micturition and slurring of speech

No C/O loss of consciousness, seizures, headache, involuntary defecation, vomitings, fever, trauma, diplopia.

History of past illness:-

H/o CVA with right sided hemiparesis 3 years back, recovered now

K/C/O Hypertension since 4 years ( not using medication regularly in past few days)

N/K/C/O DM,TB, Epilepsy,CAD, Thyroid disorders, Bronchial asthma

Personal history:-

Diet - Mixed

Appetite - Normal

Bowel and bladder - regular

Sleep - adequate

No addictions

No H/o food and drug allergies

Family history:-

Not significant

General examination: -

Patient is conscious, coherent, cooperative, moderately built and nourished

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and oedema

VITALS :-

Temp- 97.8F

BP-150/90 mmHg

PR- 68 bpm

RR - 18com

Sp02-97%

Systemic examination:

CVS- S1;52 + , no murmors

RS- BAE+ NVBS heard

P/A- Soft non tender, no organomegaly

CNS :-

Patient is arousable

No signs of meningeal irritation

Tone:

            Right.                         Left 

UL       Increased.         Increased 

LL.      Increased.            Increased 

Power:

         Right.             Left 

UL.     2/5.          3/5

LL.     2/5.          3/5 

Reflexes.    Rt.     Lt 

-Biceps.      3+.     3+

Triceps.      3+.      3+

Supinator   2+.       2+

Knee.          3+.      3+

Plantar.  extension  extension

INVESTIGATIONS ;-

    

     

 

  

PROVISIONAL DIAGNOSIS 

 Recurrent CVA asso with right side Hemiparesis with Hemorrhagic infarct in Left fronto parietal region 

 

    TREATMENT 

    19/10/2023 

     1) RT feeds - 100 ml H20 2 hrly

                            200 ml milk 4 hrly 

      2) IV fluids NS @30 ml / hr 

     3)inj mannitol 100ml IV /TID ( 8am , 2pm, 8pm ) 

     4)inj levipil 500mg IV/BID ( 8am ,8pm ) 

     5) vitals monitoring houlrly 

     6) inform SOS 

   20/10/2023 

  1) RT feeds 100 ml water 2 hrly 

                      200ml milk 4 hourly 

  2)IVF NS @50ml/hr

  3)Inj Mannitol 100ml IV /TID

  4)inj levipil 500mg iv/bid

  5)inj pantop 40mg IV

21/10/2023

  IV fluids NS, DNS @ 50ml/ hr

Inj. Mannitol 100ml i.V/TID

Inj. Levipil 500mg iv/bd

Tab.Amlong 5mg PO/CD

Syrup. Potchlor 10ml in 1 glass water po/tid

GRBS 4th hourly monitoring

Vitals monitoring hourly