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.
GM Referral from OPTHAMOLOGY
AMC case
A 62 year old female presented with c/o
Inability to lift right upper and lower limb since 4hrs
Inability to speak since 4hrs
Deviation of mouth to left since 4 hrs
The patient was apparently assymptomatic
6months ago ,then she developed diminission of vision in the left eye ,insidious in onset and gradually progressive
She was admitted in ophthalmology dept on 27/10/21 and diagnosed to be having immature senile cataract
She underwent cataract surgery to the left eye on 30/10/21
31/10/21
At around 4 am in the morning she fell from bed after which she had deviation of mouth to left and unable to lift her right upper and lower limbs, unable to speak and was referred to general medicine dept
PAST HISTORY
Under went right cataract surgery 3 yrs ago
K/c/o HTN since 10 years on tab.telma h ( 40/12.5 ) mg po od
K/c/o Type 2 DM since 5 years
On tab.glyciphage sr 500 mg po od
Not a k/c/o TB ,asthma ,epilepsy ,CAD
PERSONAL HISTORY
Married
Takes mixed diet
Appetite - normal
Sleep - adequate
Bowel and bladder movements - regular
No known addictions and allergies
GENERAL PHYSICAL EXAMINATION
Pt is conscious, coherent, cooperative
Moderately built and nourished
No pallor ,icterus, clubbing ,cyanosis lymphadenopathy,odema of feet.
Vitals
Pr- 96 BPM
Bp- 120/70 mm hg
Rr - 18 cpm
SYSTEMIC EXAMINATION
Cvs- S1,S2
Rs - bae+, nvbs+
P/a - soft ,nontender,bowel sounds +
CNS - higher mental functions intact
PUPILS -
Rt - pinpoint pupil
Lt - reacting to light
Speech - aphasia
Power UL LL
Rt. 0/5. 5/5
Lt. 4/5. 5/5
Tone Rt Decreased. Normal
Lt decreased Normal
Reflexes
B T S K A P
Rt. 1+ 1+ - 2+ - flexor
Lt 2+ 1+ 1+ 2+ 2+ Flexor
CT BRAIN
Impression:-
-Chronic lacunar infarcts noted in bilateral lentiform nucleus.
-diffuse cerebral atrophy
-?left occipital bone fracture
Provisional diagnosis
RIGHT HEMIPARESIS
Acute CVA
INVESTIGATIONS
Serology - Negative
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