A 70 yr old male patient

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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 with collective current best evidence based inputs. 
Date of Admission: 19/7/22

CHIEF COMPLAINTS 
This is a case of 70yr old male who presented to the casualty with Chief Complaints of 
                   - Seizure episode with involuntary micturition 
HOPI
Patient was apparently asymptomatic 5 months back and them he developed brain stroke for which he uses medication which should be continued for lifelong and on 19 July he presented to casualty with an episode of seizure which involved involuntary movements of both upper and lower limbs and involuntary micturition. After admitting he developed another 2 episodes of seizures with involuntary micturition   for which he recieved  inj.lorazepam 2cc  i.v stat , Mannitol 100 ml i.v stat, Inj.levipil 1gm i.v stat. 


PAST HISTORY 
Operated for stones in urinary bladder few yrs  back
Operated on vertebral column few yrs back 

History of CVA Ischaemic Stroke Rt PCA Stroke on FEB 2022

Known case of Hypertension 

N/ K/c ,Diabetes,TB,Asthma

FAMILY HISTORY 

NO relavent family history

PERSONAL HISTORY 

Diet:Mixed type
Appetite: Normal 
Micturition: Normal
Bowel and Bladder movements: Constipation 
Sleep: adequate 
Addictions: 
Consumes bd from 15 yrs of age  but stopped 2 months back
  
GENERAL EXAMINATION
No Sign of Icterus,cyanosis,clubbing,Lymphadenopathy,
oedema
Blurr vision
VITALS
Temp: Afebrile
Pulse rate:120bpm
Respiratory rate: 20/ min
BP: 210/120 mm Hg
IncoSpO2: 96%
GRBS: 178 mg%
SYSTEMIC EXAMINATION 

C V S : SI and S2 Heard
No murmurs

Respiratory System : BAE+, left IAA crepts  + 

Per abdomen: soft and nontender 

Non palpable no organomegaly.

Normal Reflexes 
 CNS: 
 Level of consciousness: stuporous
Speech : Incoherent
Pupils: Anisocoria
No signs of Meningitis
MOTOR SYSTEM: Power can't be elicited,
                                Tone is Normal
GLASGOW COMA SCALE: E2V2M5

PROVISIONAL DIAGNOSIS
SEIZURES WITH DECREASED EVALUATION

INVESTIGATIONS 
19/7/22
19/7/22
19/7/22
TREATMENT
19/7/22 
1. Inj.Mannitol  100 ml i.v TID
2. Inj LEVIPIL 1 gm i.vstat to 500 mg iv BD
3.Inj.PANTOP 40 mg iv OD 
4. Inj. ZORER 4mg IV/SOS
5. Inj.LORAZ 2cc IV/SOS( if seizures present) 
6. BP Monitering 4th hrly
7. I/O Charting 
8. PHYSIOTHERAPY
9. Frequent change of posture 
10.GRBS 6th hrly - 148 mg/dl

20/7/22
Right feed - 100 ml Milk 4th hrly and 50 ml water 2nd hrly
Inj. OPTINEURON  1 amp in 500 ml NS IV/ OD
Inj LEVIPIL  500 mg iv BD
Inj. PIPTAC 4.5 g IV TID
Inj.PANTOP 40 mg iv OD 
4. Inj. ZOFER 4mg IV/SOS
5. Inj.LORAZ 2cc IV/SOS( if seizures present) 
6. BP Monitering 4th hrly
7. I/O Charting 
8. PHYSIOTHERAPY
9. Frequent change of posture 
Pt is irritable
PR : 100 bpm
BP: 110/80
SpO2: 95%
CVS : S1 S2 + 
R/S: BAE+ 
CNS: Pt is drowsy but arousable
GCS: E3V1M6
Pupils: NSRL, Rt cataract + 
Stools : Not passed
GRBS: 155 mg/dl
I/O: 1200/1300
21/7/22

BP: 130/80 mm Hg
PR: 86 BPM
CVS: S1 S2 + 
RS: BAE+
GCS: E4V5M6
Pupils: NSRL
GRBS: 144 mg/dl
I/O: 1400/1400








        












Comments

Post a Comment

Popular posts from this blog

13 yr old female

Image
This is online E log book to discuss our patients health data shared after taking his guardians informed consent form I have been given this case to solve in an attempt to understand topic of" patient clinical data analysis" to develop my competency in reading and comprehensing clinical data including history clinical findings  investigations and come with a diagnosis and treatment plan.  This is a case of 14 yr old female diagnosed with Sickle cell anaemia have multiple admissions for sickle cell crisis  now presented  with chief complaints of        - Joint pains more at night         - Right knee pain since 15 days         - left leg shin pain HOPI Patient was apparently asymptomatic 10 yrs back and diagnosed as Sicke cell anaemia with known history of Abdominal pain, yellowish discoloration of eyes,SOB,fever,dry cough, pleural tap  and she had  blood transfusion 15 times since childhood and had multiple episodes of sickle cell crisis  and brochopneumonia  and pancreatitis
Read more

OSCE LEARNING POINTS

OSCE LEARNING POINTS    1. What is PUO?  Increase in body temperature more than 38.3 °C (101.0 °F) for at least 21 days or three weeks without any established aetiology (cause) after being a thorough clinical evaluation 2.Types of PUO? CLASSICAL PUO: Increase in body temperature for more than 3 weeks and duration of hospital stay is 3 days or 3 outpatient visits without detecting a cause or 1 week of thorough investigations  NOSOCOMIAL PUO: Temperature of more than 38.3 C developing on several occasions in a  Hospitalized patient in whom infection was not manifested or incuabting on admission  with 3 days of investigations including atleast 2 days incubation  of cultures NEUTROPENIC PUO: Temperature of more than 38.3 C developing on several occasions in a patient whose neutrophil count is less than 500/ microlit or expected to fall in 1-2 days . HIV ASSOCIATED PUO:Temperature of more than 38.3 C on several occasions for a period of more than 4 weeks for outpatient or  more than 3 days
Read more

40YR OLD MALE WITH CKD

Image
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed 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 with collective current best evidence based inputs.  CHIEF  COMPLAINTS PT IS BROUGHT TO CASUALITY  WITH  C/O PAIN ABDOMEN SINCE 2 DAYS         VOMITING SINCE 1 DAY         DECREASED  URINE OUTPUT SINCE 1 DAY         NO URINE OUTPUT SINCE 8 HOURS HOPI- PT WAS APPARANTLY ASSYMPTOMATIC 3 DAYS BACK THEN HE DEVELOPED PAIN ABDOMEN ; DRAGGUNG TYPE OF PAIN IN EPIGASTRIUM AND UMBILICAL REGION NOT RADIATING INCREASE WITH FOOD INTAKE DISTENTION OF ABDOMEN IS PRESENT VOMITINGS PRESENT 1 EPISODE PER DAY NOT BILIOUS AND NON PROJECTILE  NOT BLOOD TINGED DECREASED URINE OUTPUT SINCE 1 DAY NO FACIAL PUFFINESS,FEVER,BURNING MITURITION. NO H/o SOB, CHEST PAIN,BLURRING O
Read more