CBBLE UDHC SIMILAR CASES
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT A 65Y MALE WHO IS A DAILY WAGE LABOURER (SHEPHERD SINCE 10YRS) , CAME WITH COMPLAINTS OF WEAKNESS OF RIGHT UPPER LIMB AND LOWER LIMB SINCE 5 DAYS.
HOPI:
PATIENT WAS APPARENTLY ASYMPTOMATIC 7YRS BACK.
PATIENT HAD DINNER AROUND 8PM AND WENT TO SLEEP AROUND 2PM,HE WENT TO URINE AND SUDDENLY FELL IN BATHROOM, DIAGNOSED WITH RIGHT SIDED CVA AND ADVISED MEDICATION AND DISCHARGED.
IT TOOK AROUND 2-3 MONTHS TO WALK.NO SLURRING OF SPEECH AT THAT TIME,NO LOC.USED MEDICATION FOR 1YR AND STOPPED MEDICATION ON HIS OWN. RECOVERED APPROXIMATELY 75-80% (IN THEIR ATTENDERS LANGUAGE).
DIAGNOSED WITH HTN DURING ROUTINE CHECKUP AND STARTED ON ANTIHYPERTENSIVES BUT LATER STOPPED (AFTER 1 YR)
ONE WEEK BACK ,PT C/O UNABLE TO WAKEUP EARLY MORNING AFTER PASSING URINE.
C/O SLURRING OF SPEECH + , ABLE TO FEEL BLADDER FULL SENSATION.
C/O DYSPHAGIA +
C/O COUGH SINCE 3 DAYS.
NO C/O INVOLUNTARY DEFECATION
NO C/O CHEST PAIN, SOB, PALPITATIONS.
PAST H/O :
K/C/O HTN SINCE 1 YEAR WAS ON MEDICATION BUT STOPPED LATER
NOT A KNOWN CASE OF DM, BA, TB, CAD.
PERSONAL HISTORY:
DIET - MIXED,
APPETITE -NORMAL ,
BOWEL MOVEMENT - REGULAR , PASSED STOOLS 3 DAYS BACK
BLADDER MOVEMENTS - ABNORMAL
HABIT OF ALCOHOL CONSUMPTION (OCCASIONAL)
NO OTHER ADDICTIONS
NO KNOWN DRUG ALLERGIES
FAMILY HISTORY: NOT SIGNIFICANT
ON EXAMINATION
PATIENT IS CONSCIOUS, COHERENT,COOPERATIVE
NO SIGNS OF PALLOR ,ICTERUS, CLUBBING, CYANOSIS, LYMPHADENOPATHY, PEDAL EDEMA.
VITALS:
TEMP: 98.6°F
PR: 100 BPM
BP:110/80 MMHG
SPO2: 94% ON RA
GRBS: 83mg%
SYSTEMIC EXAMINATION:
CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS HEARD
RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS HEARD
PER ABDOMEN:
SHAPE OF THE ABDOMEN : OBESE
SOFT, NONTENDER, NO ORGANOMEGALY
CNS:
PATIENT IS CONSCIOUS WITH SLURRED SPEECH
NO NECK STIFFNESS ,
- RIGHT LEFT
1) TONE UL NORMAL NORMAL LL NORMAL NORMAL
2) POWER UL 4/5 4/5
LL 3/5 4/5
3) HANDGRIP 100%
4) REFLEXES
a) BICEPS 3+. 2+
b) TRICEPS 3+. 2+
c) SUPINATOR 3+ 2+
d) KNEE 2+. 1+
e) ANKLE - -
f) PLANTAR extensor flexor
INVESTIGATIONS:
HEMOGRAM:
HB: 15.4
TLC: 8,700
N/L/E/M/B: 78/12/02/08/00
PCV: 43.7
MCV: 37.8
MCH: 30.9
MCHC:35.2
RBC:4.98
PT:2.18
RDW-CV :13
RDW-SD: 42.5
PS: NC/NC
RFT:
BLOOD UREA : 22 MG/DL
SERUM CREATININE: 1.1
SERUM ELECTROLYTES:
Na+ : 135
K+: 4.1
Cl-: 98
LFT
TB: 2.11
DB: 0.94
SGOT:41
SGOT:26
ALP: 98
TP:7.4
ALBUMIN:3.83
A/G: 1.07
SEROLOGY: NEGATIVE
HBA1C : 6.5%
PLBS: 108mg/dl
SER.LIPID PROFILE:
Total cholesterol: 196mg/dl
Triglycerides: 157mg/dl
HDL: 1.03
LDL:94
VLDL:31
TFT(10/2/22):
T3:1.03
T4;14.97
TSH:1.45
ECG:
CXR
TRIVIAL TR+ / MR + / MILD ARD
GOOD RV& LV SYSTOLIC FUNCTION +
NO RVMA , MIXED LVH + ,NO PAH
MINIMAL PE+ ; DIASTOLIC DYSFUNCTION +
CT BRAIN: (DONE OUTSIDE ON 5/2/22)
ILL DEFINED PATCHY HYPODENSITY IN LEFT BODY OF CAUDATE NUCLEUS AND LEFT CORONA RADIATA-? SUBACUTE TO CHRONIC INFARCT
CHRONIC LACUNAR INFARCTS IN BILATERAL CAPUSLOGANGLIONIC REGIONS AND BILATERAL CORONA RADIATA
DIFFUSE CEREBRAL ATROPHY
CHRONIC SMALL VESSEL ISCHEMIC CHANGES
USG ABD AND PELVIS:(10/2/22)
NO SONOLOGICAL ABNORMALITY DETECTED
COLOR DOPPLER(10/2/22)
MRI BRAIN(11/2/22):
-Acute infarcts in right caudate nucleus,putamen, internal capsule and adjacent corona radiata.
-Mild diffuse cerebral and cerebellar atrophy with small vessel ischaemic changes.
TREATMENT PLAN
T.CLOPITAB 75MG PO/OD
T.ECOSPIRIN 75MG PO/OD
T.ATORVAS 20MG PO/OD
T.PAN 40 MG PO/OD
SOAP NOTES
DAY 1:
S: Patient c/o cough
O:
Pt c/c/c
Temp:- 98.6°F
PR 86
SPO2 97%
GRBS 87mg%
BP 130/80mmhg
CVS: S1S2 HEARD
RS: BAE+
P/A: SOFT,NONTENDER
CNS RIGHT. LEFT
POWER
UL. 3/5 3/5
LL 4/5 4/5
TONE
UL. . increased normal
LL. increased normal
4) REFLEXES
a) BICEPS 3+ 2+
b) TRICEPS 3+ 2+
c) SUPINATOR 3+ 2+
d) KNEE 3+ 2+
e) ANKLE. - -
f) PLANTAR extensor flexor
A: Subacute R sided CVA with Subacute infarct in L CAUDATE nucleus & L corona RADIATA with hypertension
P :
T. Clopitab 75mg
T. Ecospirin 75mg
T. Atorvas 20mg
T. Pan 40 mg
T. Monteleukast
Syp.Ascoril
Planned for 2decho and Color Doppler
DAY 2:
S: Patient c/o cough
O:
Pt c/c/c
Temp:-98.8°F
PR 92
SPO2 98%
GRBS 94mg%
BP 140/90mmhg
CVS: S1S2 HEARD
RS: BAE+
P/A: SOFT,NONTENDER
CNS RIGHT LEFT
POWER
UL 3/5 3/5
LL 4/5 4/5
TONE
UL. increased normal
LL. increased. normal
REFLEXES
a) BICEPS. 3+ 2+
b) TRICEPS 3+ 2+
c) SUPINATOR 3+ 2+
d) KNEE. 3+ 2+
e) ANKLE - -
f) PLANTAR extensor flexor
A: Subacute R sided CVA with Subacute infarct in L caudate nucleus & L corona radiata with hypertension
P :
T. Clopitab 75mg
T. Ecospirin 75mg
T. Atorvas 20mg
T. Pan 40 mg
T. Monteleukast
Inj.optineuron
Inj.Augmentin
Syp.Ascoril
Planned for MRI BRAIN, repeat cxr
DAY 3:-
S:Patient c/o cough, one fever spike yesterday night
O:
Pt c/c/c
Temp:97°F
PR 85bpm
SPO2 96%
GRBS 170mg%
BP 150/90mmhg
CVS: S1S2 HEARD
RS: BAE+
P/A: SOFT,NONTENDER
CNS RIGHT LEFT
POWER
UL. 3/5 3/5
LL 4/5 4/5
TONE
UL. increased normal
LL. increased normal
REFLEXES
a) BICEPS. . 3+ 2+
b) TRICEPS 3+ 2+
c) SUPINATOR 3+ 2+
d) KNEE. 3+ 2+
e) ANKLE - -
f) PLANTAR extensor flexor
A: Subacute R sided CVA with Subacute infarct in L caudate nucleus & L corona radiata with hypertension
P :
T. Clopitab 75mg po od
T. Ecospirin 75mg po od
T. Atorvas 20mg po od
T. Pan 40 mg po od
T. Monteleukast po od
T.Amlong 5mg po od
T.Pcm 500mg po qid
Inj.optineuron 1ampin100ml/ns/od
Inj.Augmentin 1.2mg/iv/tid
Syp.Ascoril 5ml po tid
Monitor Temp/Bp/grbs 4th hrly
Planned for Fundoscopy
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