10 ANUSRI CASE STUDY -2

CASE STUDY

Oct 4 , 2021

This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.

This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.

I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.

CASE:

69 year old female was brought to the causality with a complaint of sudden onset of aphasia preceded by 2 episodes of vomiting.She was apparently asymptomatic before.After then she had 2 episodes of vomiting and after which she had difficulty in speech, generalised weakness, staring look at times, difficulty in walking, walking with support, patient is unable to recognise her family members. She had similar episodes 10 days back i.e vomiting associated with weakness and disorientation.  Patient was given adequate food and fluids at home and she became stable in 2 days.

Complaints and Duration:

sudden onset of aphasia preceded by 2 episodes of vomiting

Staring look

Associated with involuntary movements

rolling of eye balls

Tongue bite   (-ve)

History of present illness:

Involuntary micturition and defecation

History of past illness:

Not a known case of diabetes Miletus, tuberculosis, hypertension, thyroid and asthmatics 

No h/o seizures, head injury

No h/o substance abuse

No h/o fear, repetitive thought of action

Decrease in sleep, decrease in appetite

Self care and hygiene not maintained

Personal history:

Non alcoholic

Doesn’t smoke

Non vegetarian 

Treatment history:

Not significant

General examination:

30/9/2021:

Conscious (confused)

Intermittent coherence

Speech: response to few commands

2/10/2021:

Irrelevant talk intermittently

No fresh complaints

4/10/2021:

Irritability and irrelevant talk reduced

Patient is able to recognise family members at times and hallucinating behaviour decreased

Vitals:

30/10/2021:

BP: 120/60 mm Hg

PR: 84bpm

1/10/2021:

Temp: Afebrile

BP:110/60mm Hg

PR: 88 bpm

2/10/2021:

Temp: 97.5 F

BP: 120/60mm Hg

PR: 86 bpm (regular)

3/10/2021:

Temp 97.5 F

BP: 110/80mm Hg

PR : 88bpm regular

Systemic examination:

1/10/2021: 

CVS: S1 S2 + no murmur

RESP SYS: Resonated breath sounds in B/L ISA

P/A - soft, no tenderness

CNS: 

                            RT           LT

TONE:      UL:   2/5           2/5

                   LL:    2/5           2/5

POWER: UL:     2/5           2/5

                LL :     2/5           2/5

REFLEX:  B     T     S      A     K     P

                   -      -      -       -       -      F

                   -      -       -       -      -       F

2/10/2021:

CVS: S1S2 + Nomurmur

Rs: NVB1 decreased breath sounds in lt RSA

P/A soft, no tenderness

I/O 2200/1600 ml

GRBS 152 mg/dl

3/10/2021:

CVS: S1S2 + Nomurmur

Rs: NVB1 decreased breath sounds in lt RSA

P/A soft, no tenderness

I/O 1550/1400 ml

GRBS 150mg/dl

Medication chart:

1/10/2021:

INJ.PAN 40mg i.v OD

INJ.ZOFER 16mg i.v SOS 

TAB. DOLO 650mg PO OD

INJ.OPTINEURO 650mg OD

INJ.MONOCEF 1g I.v OD

2/10/2021:

INJ. PAN 40mg I.v OD

INJ.ZOFER 4mg I.v SOS

TAB. DOLO 650mg PO SOS

SYP.ABROXY 10 mg PO TID

INJ.MONOCEF 1g I.v BD

TAB.ADMENTA 10mg PO OD

TAB.OLANZAPINE 5mg PO OD

3/10/2021:

INJ.PAN 40mg I.v OD

INJ.ZOFER 4mg I.v SOS

INJ.MONOCEF 1g I.v BD

INJ.DOLO 650mg PO SOS

SYP.AMBROXYL 10ml PO SOS

TAB.OLANZAPINE 5mg PO OD

4/10/2021:

INJ.PANTOP 40mg i.v OD

INJ.ZOFER 4mg i.v SOS

TAB.DOLO 650mg PO TID

SYP.AMBROXYL 10ml PO TID

INJ.MONOCEF 1g I.v BD

TAB.ADMENTA 10mg PO OD

TAB.OLANZAPINE 2.5mg PO OD

INJ.HALOPERIDOL 1/2amp/I.M/SOS(if patient is irritable)

INJ.LACTULOSE 15ml/PO/HS

IVF (NS and RL) 75ml/hr

1amp of OPTINEURON I.v OD


INVESTIGATIONS:

1. COMPLETE BLOOD PICTURE:





2.MRI





3. CBP, serum electrolytes, LFT



4. ECG




 OTHER INVESTIGATIONS:






PROVISIONAL DIAGNOSIS:

Wernickes Aphasia



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