General Medicine E log

 

M.Anurag, MBBS 8th semester

Roll no:72

This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on 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 a diagnosis and a treatment plan.

 

(Contains information collated from Dr.Manasa PG and from the patient)

CASE DISCUSSION:

A 57 year old female patient , resident of xxxx, presented to casuality with complaints of weakness of the left lower limb

HISTORY OF PRESENTING ILLNESS:
•Patient was apparently asymptomatic four days ago, then she developed weakness of the left lower Limb which was insidious in onset, duration for about 1-2 hours and was relieved on medication. She was normal for 2 to 3 days then she again develop weakness of left lower limb with deviation of the mouth to the right side since today morning.

•Patient had a history of deviation of mouth to the right side since 4 years
•Slurring of speech was present
•There is no history of headache, vomitings fever and seizures.
•No history of involuntary defecation or micturition.

PAST HISTORY:
•The patient had similar complaints in the past two years back for which she used an Antiplatelet medications for 2-3 months and then stopped.
•She is a known case of  Diabetes Mellitus type 2 since 4 years and is on OHA's.
•The patient is a known case of  Hypertension since 5 years and uses
     TAB.AMLONG 5MG
     TAB. TELMA 40MG
     TAB.HYDROCHLORTIAZIDE 12.5MG

PERSONAL HISTORY:
Diet : mixed

Appetite: normal 

Sleep: adequate

Bowel and bladder habits: regular

Addictions: She takes toddy and alcohol occassionally.

GENERAL EXAMINATION :

•Patient is conscious, coherent, co- operative and well oriented to time place and person and was examined in a well lit room

•No signs of pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy.

VITALS:
Temp: Afebrile
PR: 113 bpm
BP: 180/90mm HG
RR: 22 cpm
SPO2: 98% at room air
GRBS: 180mg/dl

SYSTEMIC EXAMINATION:

Central Nervous System:
Cranial nerves: Intact
Sensory system: sensitive to touch and  pain
Motor system:
                         Right                 Left
Power:  UL      4/5                    4/5
               LL      4/5                   4/5/3/5

Tone:     UL    Normal             Normal
               LL    Normal            Decreased

Reflexes:
Biceps            ++                       ++
Triceps           ++                       ++
Supinato        +                          +
Knee               -                            -
Ankle              -                            -
Plantar       Flexion              Extension
response

Gait:Hemiplegic

Cerebellar system: Intact

Cardiovascular system: 

S1 and S2 heard, no murmurs

Respiratory System: 

Normal vesicular breath sounds in all areas, BAE+

Per Abdomen:

soft, non tender, bowel sounds+

PROVISIONAL DIAGNOSIS:
cerebrovascular accident causing  monoparesis and left upper motor neuron plasy with acute infarct in the right external capsule, corona radiata, right caudate nucleus, right putamen right renal simple cortical cyst.

TREATMENT:

1. IVF NS AND RL @50ML/HR
2. Tab.METFORMIN 500MG PO/BD
3. Tab.ASPIRIN 150MG PO/OD
4. Tab.CLOPIDOGREL 75MG PO/OD/H/S
5. Tab.ATORVAS 40MG PO/OD/H/S
6. PHYSIOTHERAPY OF THE LEFT LOWER   LIMB AND FACE.

                               DAY 1:

                         SOAP NOTES

S:
NO FRESH COMPLAINTS

O:
Temp: Afebrile
PR: 107 bpm
BP: 120/70mm HG
RR: 22 cpm
SPO2: 98% at room air
Systemic examination:
Central Nervous System:
Cranial nerves: Intact
Sensory system: sensitive to touch and  pain
Motor system:
                         Right                 Left
Power:  UL      4/5                    4/5
               LL      4/5                   4/5/3/5

Tone:    UL    Normal             Normal
               LL    Normal            Decreased

Reflexes:
Biceps            ++                       ++
Triceps           ++                       ++
Supinato        +                          +
Knee               -                            -
Ankl                -                            -
Plantar       Flexion               Flexion
response

Gait: Hemiplegic

Cerebellar system:  Intact

CardiovascularSystem: 

S1 and S2 heard, No murmurs present

Respiratory system:

Non Vesicular Breath sounds heard in all areas

Bilateral Air Entry present

Per Abdomen: 

Soft, Non Tender, Bowel Sounds present

A

Cerebrovascular accident
with monoparesis with left upper motor neuron plasy with acute infarct in the right external capsule, corona radiata, right caudate nucleus, right putamen.

P

1.IVF NS AND RL @50ML/HR
2.T. METFORMIN 500MG PO/BD
3. T. ASPIRIN 150MG PO/OD
4. T. CLOPIDOGREL 75MG PO/OD/H/S
5.T. ATORVAS 40MG PO/OD/H/
6.PHYSIOTHERAPY OF THE LEFT LOWER LIMB AND FACE.

DAY 2:

SOAP NOTES

S-
NO FRESH COMPLAINTS

O-

Temp: Afebrile
PR: 96 bpm
BP: 150/90mm HG
RR: 21 cpm
SPO2: 99% at room air
Systemic examination:
Central Nervous System:
Cranial nerves: Intact
Sensory system: sensitive to touch and  pain
Motor system:
                          Right                 Left
Power:

               UL      4/5                    4/5
               LL      4/5                   4/5/3/5

Tone:  

               UL    Normal             Normal
               LL    Normal            Decreased
 
Reflexes:
Biceps            ++                       ++
Triceps           ++                       ++
Supinato         +                          +
Knee                -                            -
Ankl                 -                            -
Plantar       Flexion               Flexion
response

Gait: Hemiplegic

Cerebellar system:  Intact

CardioVascularSystem: 

S1 S2 +

Respiratory system: 

Non Vesicular Breath Sounds observed in all areas, 

Bilateral Air Entry present 

Per Abdomen: 

Soft, Non Tender, Bowel Sounds present

A:

Cerebrovascular accident
with monoparesis with left upper motor neuron plasy with acute infarct in the right lentiform nucleus extending into corona radiata

P:

1.IVF NS AND RL @50ML/HR
2.T. METFORMIN 500MG PO/BD
3. T. ASPIRIN 150MG PO/OD
4. T. CLOPIDOGREL 75MG PO/OD/H/S
5.T. ATORVAS 40MG PO/OD/H/S
6.PHYSIOTHERAPY OF THE LEFT LOWER LIMB AND FACE.