75yr Old F Altered Sensorium

Hello all this is Sri Harshitha 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




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