** This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.
Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.
Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.
This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end.
I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.
CASE SHEET
Chief complaint: Swelling of tongue, dizziness, inability to speak clearly.
History of presenting illness: Patient was asymptomatic 13 days back.
She was cleaning her house and preparing it for the occasion of Diwali when she suddenly fell on her side. While falling her body hit the wall and there was a lot of bruising, chest and abdomen were tender to touch.
Upon excessive pain she went to an RMP who suggested her to take rest but did not prescribe any medication. She returned home but the pain was not alleviated.
She then went to another RMP who prescribed medication, the name if which she does not recall, upon taking this medication she developed swelling of tongue and dizziness.
This was 2 days ago. Upon experiencing these symptoms she decided to come to our hospital and got admitted to the ICU.
History of past illness: Patient has hypertension since the past 10 years and Diabetes since the past 6 years.
6 years ago she underwent a hysterectomy.
Post surgery, the suture wounds weren't healing well because of which she was screened for her blood sugar levels upon which she was diagnosed with type 2 diabetes mellitus.
There is no history of TB, asthma, epilepsy, COVID etc.
Drug history: Patient has been taking a combination of metformin hydrochloride and gimeperide for type 2 diabetes mellitus.
She also takes Java juice daily at lunch time which the patient and her attender said is a remedy for controlling blood sugar levels.
Patient has been taking a combination of amlodipine and atenolol for hypertension.
10 days ago patient took the first dose of the COVID vaccine.
Personal history: Patient is married and is a housewife. Her husband works at the collecterate office.
Patient is a non vegetarian and has a mixed diet with normal appetite. Bladder movement is normal.
Since 3 days she has constipation.
Family history: No relevant family history
General examination:
Patient is conscious, coherent and cooperative. She is well oriented to place,time and people.
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Koilonychia: Absent
Lymphadenopathy: Absent
Edema: Absent
Vitals:
Temperature: afebrile
Respiratory rate: 14 breaths per minute
Pulse : 78 beats per minute
Blood pressure: 100/60 mm of Hg
CVS examination:
S1 and S2 are heard. No murmurs. On 2D echo screening no clots are seen everything appears normal. IVC dilated to 1.67 cm not collapsible.
Respiratory system examination:
No vesicular sounds, wheezing or crepitation.
CNS examination:
Higher functions: Patient is coherent, cooperative and well oriented to time space and people. Her memory is fine, she recollects both short and long term memories.
Speech: Patient is able to pronounce isolated syllables but not jointed or complex syllables as heard in the words "Amritsar", "artillery", "yudhishthir". Patient slurs the words suggestive of a lesion in the cortex/brocas area/ pyramidal tracts.
Gait is normal but patient feels dizzy after walking.
Cranial nerves: Normal except: Horizontal and vertical nystagmus is present.
Sensory functions are normal.
Motor functions are normal.
Reflexes normal
Cerebellar functions: Normal?
Provisional Diagnosis: Spastic dysarthria due to acute infarction.
Treatment:
H. A insulin 16 IU
H. A Insulin 6 IU
H. Atrapid insulin infusion
Inj. Pantop.
Along with Tab. Ecospirin 150/20?
Tab. Clopidogrel 150 mg
Tab. BPlexforte
Comments
Post a Comment