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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.
38 YR OLD FEMALE CAME WITH THE C/O SEIZURES SINCE 4 DAYS .
Patient was apparantly asymptomatic 20 days back then she had fever , headache , cough , cold for which she had taken treatment from the local hospital , from then she had on and off fever with generalized wekness and 4 days back she had slurring of speech for which she went to a local hospial and there she had episode of seizure involving right upper limb and deviation of mouth , associates with tongue bite ,episode lasted for 5 min . No H/o loss of consciousness , involuntary micturition , involuntary defecation . Again 6 more episodes of right upper limb unilateral focal seizures on the next 3 days that is 2 episode each night .from there she was referred to our hospital for further treatment .
PAST HISTORY
K/C/O poliomyelitis since 3 years of age (5 -10 days post vaccination)
Not a k/c/o DM , HTN , CAD , ASTHMA , TB .
Underwent surgery for removal of ? Lipoma 8 years ago .
PERSONAL HISTORY
Married
Occupation :Tailor ( sweing with hand )
Diet : mixed
Appetite : decreased
Bowel and bladder : Regular
No addictions .
No known allergies .
FAMILY HISTORY
No K/C/O HTN , DM, ASTHMA , THYROID , TB , EPILEPSY in the family .
MENSTRUAL HISTORY
- Age of menarche : 12 years
- Regular cycles , 4-5 days bleeding for every 30 days .
No pain and No clots
No c/o heavy menstrual bleeding .
MARITAL HISTORY
Age at time of marriage - 28 years
Age of her husband at time of marrige - 32 years .
Non consaguinous marriage.
Marital life - 9 years .
Both patient and her husband used some herbal medications for a week for infertility two years after marriage and later they did not
Use any medications for infertility.
Patient husband is k/c/o diabetic since last 1 year and not on any medication .
DAILY ROUTINE
She was homemaker and wakes up daily at 6 am in the morning followed by daily chores and eats breakfast (rice with curry) and then countinues her daily household work and takes lunch around 2-3 pm. Later she finishes the works which were pending in the morning and then have her dinner around 7:30 pm and sleeps aorund 8:30 - 9 :00 pm.
GENERAL EXAMINATION
Patient is conscious , cooperative
No Pallor, icterus ,cyanosis, clubbing , lymphadenopathy , edema.
VITALS
TEMP : 98.6
BP : 120/ 80 mmhg
PR : 92/ min
RR : 20/ min
Spo2 : 98% on RA
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , NVBS
P/A : SOFT , NON TENDER
CNS :
PATIENT IS CONSCIOUS ,
SPEECH : SLURRED
SENSORY SYSTEM : INTACT
FACIAL DEVIATION TOWARDS LEFT SIDE.
MOTOR SYSTEM :
R L
TONE UL Hypotonic Normal/hypotonic
LL Hypotonic Hypotonic
POWER UL 1/5 3/5
LL 1/5 3/5
REFLEXES
B T S K A P
R 1+ 1+ - - - Extensor
L 1+ 1+ 1+ - - Extensor
PROVISNAL DIAGNOSIS
Seizures secondary to hemorrhagic infarct - left parietal lobe .
? CSVT
RIGHT HEMIPARESIS WITH BROCA'S APHASIA
INVESTIGATIONS
30/10/21
Serology - Negative
4/11/21
PT -16 SEC.
INR- 1.1
APTT- 32 SEC
FINAL DIAGNOSIS
Right hemiparesis with brocas aphasia secondary to acute to subacute thrombus in anterior saggital sinus .
TREATMENT GIVEN
- HEAD END ELEVATION
-IVF - NS , RL @ 75 ML / HR
- INJ. LEVIPIL 500MG IV BD IN 100ML NS
- INJ . MANNITOL 100ML IV TID
- INJ. LORAZ 2CC IV SOS
- TAB. DOLO 650 MG PO SOS
- TAB. PAN 40 MG PO OD
- SYP. AMBROXOL 10ML TID
- OINT. THROBOPHOBE FOR L/A
- INJ. CLEXANE 60MG SC OD
SOAP NOTES
Day2
ICU BED 4
38 yr old female
S : NO FREASH COMPLAINTS
O :
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , NVBS
P/A : SOFT , NON TENDER
CNS :
PATIENT IS CONSCIOUS
SPEECH : SLURRED
SENSORY SYSTEM : INTACT
FACIAL DEVIATION TOWARDS LEFT SIDE.
MOTOR SYSTEM :
R L
TONE UL Hypotonic Normal/hypotonic
LL Hypotonic Hypotonic
POWER UL 1/5 3/5
LL 1/5 3/5
REFLEXES
B T S K A P
R 1+ 1+ - - - Extensor
L 1+ 1+ 1+ - - Extensor
A :
Seizures secondary to hemorrhagic infarct - left parietal lobe .
? CSVT
RIGHT HEMIPARESIS WITH BROCA'S APHASIA
P:
HEAD END ELEVATION
-IVF - NS , RL @ 75 ML / HR
- INJ. LEVIPIL 500MG IV BD IN 100ML NS
- INJ . MANNITOL 100ML IV TID
- INJ. LORAZ 2CC IV SOS
- TAB. DOLO 650 MG PO SOS
- TAB. PAN 40 MG PO OD
- SYP. AMBROXOL 10ML TID
- OINT. THROBOPHOBE FOR L/A
- INJ. CLEXANE 60MG SC OD
SOAP NOTES
Day 3
ICU BED 4
38 yr old female
S : COMPLAINTS OF PAIN AND SWELLING OF RIGHT UPPER LIMB
O :
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , NVBS
P/A : SOFT , NON TENDER
CNS :
PATIENT IS CONSCIOUS
SPEECH : MONOSYLLABLES +
SENSORY SYSTEM : INTACT
FACIAL DEVIATION TOWARDS LEFT SIDE.
MOTOR SYSTEM :
R L
TONE UL Hypotonic Normal/hypotonic
LL Hypotonic Hypotonic
POWER UL 1/5 3/5
LL 1/5 3/5
REFLEXES
B T S K A P
R 1+ 1+ - - - Extensor
L 1+ 1+ 1+ - - Extensor
A :
Seizures secondary to hemorrhagic infarct - left parietal lobe .
? CSVT
RIGHT HEMIPARESIS WITH BROCA'S APHASIA
P:
HEAD END ELEVATION
-IVF - NS , RL @ 75 ML / HR
- TAB. LEVIPIL 500MG IV BD IN 100ML NS
- INJ . MANNITOL 100ML IV TID
- INJ. LORAZ 2CC IV SOS
- TAB. DOLO 650 MG PO SOS
- TAB. PAN 40 MG PO OD
- SYP. AMBROXOL 10ML TID
- OINT. THROBOPHOBE FOR L/A
- INJ. CLEXANE 60MG SC OD
SOAP NOTES
Day 4
AMC BED 3
38 yr old female
S : NO FREASH COMPLAINTS
O :
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , NVBS
P/A : SOFT , NON TENDER
CNS :
PATIENT IS CONSCIOUS
SPEECH : SLURRED
SENSORY SYSTEM : INTACT
FACIAL DEVIATION TOWARDS LEFT SIDE.
MOTOR SYSTEM :
R L
TONE UL Hypotonic Normal/hypotonic
LL Hypotonic Hypotonic
POWER UL 1/5 3/5
LL 1/5 3/5
REFLEXES
B T S K A P
R 1+ 1+ - - - Extensor
L 1+ 1+ 1+ - - Extensor
A :
Seizures secondary to hemorrhagic infarct - left parietal lobe .
? CSVT
RIGHT HEMIPARESIS WITH BROCA'S APHASIA
P:
HEAD END ELEVATION
-IVF - NS , RL @ 75 ML / HR
- TAB. LEVIPIL 500MG IV BD IN 100ML NS
- INJ . MANNITOL 100ML IV TID
- INJ. LORAZ 2CC IV SOS
- TAB. DOLO 650 MG PO SOS
- TAB. PAN 40 MG PO OD
- SYP. AMBROXOL 10ML TID
- OINT. THROBOPHOBE FOR L/A
- INJ. CLEXANE 60MG SC OD
SOAP NOTES
Day 5
AMC BED 3
38 yr old female
S : NO FREASH COMPLAINTS
O :
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , NVBS
P/A : SOFT , NON TENDER
CNS :
PATIENT IS CONSCIOUS
SPEECH : SLURRED
SENSORY SYSTEM : INTACT
FACIAL DEVIATION TOWARDS LEFT SIDE.
MOTOR SYSTEM :
R L
TONE UL Hypotonic Normal/hypotonic
LL Hypotonic Hypotonic
POWER UL 1/5 3/5
LL 1/5 3/5
REFLEXES
B T S K A P
R 1+ 1+ - - - Extensor
L 1+ 1+ 1+ - - Extensor
A :
Seizures secondary to hemorrhagic infarct - left parietal lobe .
? CSVT
RIGHT HEMIPARESIS WITH BROCA'S APHASIA
P:
HEAD END ELEVATION
-IVF - NS , RL @ 75 ML / HR
- TAB. LEVIPIL 500MG IV BD IN 100ML NS
- INJ . MANNITOL 100ML IV TID
- INJ. LORAZ 2CC IV SOS
- TAB. DOLO 650 MG PO SOS
- TAB. PAN 40 MG PO OD
- SYP. AMBROXOL 10ML TID
- OINT. THROBOPHOBE FOR L/A
- INJ. CLEXANE 60MG SC OD
SOAP NOTES
Ward patient
38 yr old female
S : NO FREASH COMPLAINTS
O :
SYSTEMIC EXAMINATION
CVS : S1, S2 +
RS : BAE + , NVBS
P/A : SOFT , NON TENDER
CNS :
PATIENT IS CONSCIOUS
SPEECH : SLURRED
SENSORY SYSTEM : INTACT
FACIAL DEVIATION TOWARDS LEFT SIDE.
MOTOR SYSTEM :
R L
TONE UL Hypotonic Normal/hypotonic
LL Hypotonic Hypotonic
POWER UL 0/5 3/5
LL 0/5 3/5
REFLEXES
B T S K A P
R 1+ 1+ - - - Extensor
L 1+ 1+ 1+ - - Extensor
A :
Seizures secondary to hemorrhagic infarct - left parietal lobe .
? CSVT
RIGHT HEMIPARESIS WITH BROCA'S APHASIA
P:
HEAD END ELEVATION
-IVF - NS , RL @ 75 ML / HR
- TAB. LEVIPIL 500MG IV BD IN 100ML NS
- INJ. LORAZ 2CC IV SOS
- TAB. DOLO 650 MG PO SOS
- TAB. PAN 40 MG PO OD
- SYP. AMBROXOL 10ML TID
- OINT. THROBOPHOBE FOR L/A
- INJ. CLEXANE 60MG SC OD
- TAB. ACITRAM 2MG PO OD
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