Medical case disscussion
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I have been given this case to solve an attempt to understand the topic of "patient clinical analysis of data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan
CASE DISCUSSION
A 70 year old male Came with chief complaints of severe leftsided headache since 20 days associated with left ear tinnitus
HOPI
Patient was an alcoholic for 10 years uses to consume 90 ml per day and stopped 6 years ago after he developed pedal edema and was relieved in a month with treatment (didn't have any records )
Patient had diminished vision 4 years back (more in the left eye) and had left eye surgery (pterygium excision)
Patient had fever 20 days back one episode of projectile vomiting with food as content then he had
left sided headache sudden in onset more during night time ,pricking type of pain associated with giddiness intermittently . Not associated with photophobia, phonophobia
Ringing sensation in the left ear associated with pain since 20 days , unable to walk without support since 20 days
No chest pain , No palpitations, No polydypsia, No poly urea
Nocturia - present
Patient is found to be diabetic after admission
N/k/o HTN, epilepsy, CVA,CAD
GENERAL EXAMINATION
•Patient is examined in a well lit room after obtaining consent
•Patient is conscious, coherent, cooperative.
Well built and well nourished.
•No Pallor,Icterus,clubbing, cyanosis, koilonychia, edema
•VITALS
Temp- Afebrile
Bp-
PR- 76bpm
RR-18CPM
Spo2- 96%
GRBS : 240mg/dl
Systemic Examination:
CENTRAL NERVOUS SYSTEM
*Higher mental functions
Patient is conscious
Oriented to time place and person
Well dressed, well behaved ,Speech normal
Memory: intact
*Cranial nerves
Olfactory nerve: smells perceived
Optic nerve: counting fingers 6m for left eye , right eye only light perception
III, IV, VI: ocular motility normal, pupillary reflexes normal
Trigeminal nerve: jaw jerk present, corneal reflexes present
Facial nerve: intact
Vestibulocochlear nerve: normal sensory hearing
IX, X: no difficulty in swallowing
Accessory nerve: neck movements normal
*Motor system
muscle wasting present
Normal muscle tone
Power: upper limbs- right 5/5. Left-5/5
Lower limbs- right 5/5. Left- 5/5
Reflexes. Right. Left
Supinator- 2. 2
Biceps. 2. 2
Triceps. 2. 2
Knee. 2. 2
Ankle 2. 2
Coordination
Finger to nose- present
Dysdiadochokinasea- present
Sensation- pain, temperature, proprioseption, vibration felt equally on both sides
Gait- unable to walk without support
RS- bilateral air entry present
CVS : S1, S2 + no murmur, raised Jvp
P/A- soft and non tender
Examination findings :
Romberg's sign positive
Nystagmus negative
MMSC score -19 (uneducated)
Raised JVP
Diagnosis:
Provisional : Headache under evaluation ?CVA
Denovo DM-2
Investigations :
14th aug
Fbs 253
Ppbs 306
HbA1c 7%
15th aug
Serum potassium- 3.9
17th aug
Fbs 188
Final Diagnosis:
Ceribro vascular accident with Acute Infract in right occiputal, parital and frontal regions
Hyperkalemia (resolved)
Denovo DM-II
Treatment:
Glimiperide1mg + metformin500mg po/od before breakfast
Otrovin Nasal drops 3times a day for 5 days
T. Naproxen 250mg PO/BD
T. Ecosprin gold 75 PO/ HS
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