GM CASE DISCUSSION 2

Greetings to one and all who are currently reading my blog. This is Rithika, a third semester medical student. 
                     
                       This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 

Note : This is an on-going case and will be updated as and when I receive any information. 

A 60 YR OLD MALE WITH RIGHT HEMIPARESIS AND HEMORRHAGE IN THE THALAMUS

Chief complaints :

• Right sided weakness of upper and lower limbs since 10 days

History of present illness :

• Apparently the patient was asymptomatic 10 days back. 

• He developed right sided weakness of right upper and lower limbs for which he consulted some RMP and took few medications, due to which he could move his right hand a bit. 

• He was also checked for BP, and got to know that he had 140mmHg and was started on some medication by the same RMP. 

• He also felt very weak, for which IV glucose and few other injections were given, for 2-3 days. 

• Later, he developed fever( not a/w chills)and cough in the last 2-3 days. 

• No h/o deviation of mouth, slurring of speech. 

• No h/o pedal edema, cold, decreased urine output. 


History of past illness :

• Has h/o right hip replacement surgery 5 yrs back

•  Has h/o TB 4 yrs back for which he used ATT for 6 months. 

• Has no h/o DM, HTN, asthma, CAD, cancers, stroke


Treatment history:

•  Has treatment history of HTN from the last 10 days; and for TB 4 yrs ago for 6 months. 

• Has no treatment h/o DM, heart strokes, cancers, asthma. 

Personal history :

• Patient is married and has 4 children

• Follows a mixed diet

• Has normal appetite and micturition, bowel habits are normal

• Is a chronic alcoholic, since 30+ yrs, drinks almost twice a day( reduced from last 10 days) 

• Was a smoker 5 yrs ago, smoked 18 bidis/ day. 

Family history :

• Has no family h/o DM, HTN, asthma, CAD, cancers, stroke. 

General Examination :

• Has pallor

• Has no cyanosis, icterus , clubbing of fingers/ties, oedema of feet ,  lymphadenopathy ,  malnutrition

Vitals :

• PR - 89 bpm
• BP - 150/90 mmHg
• RR - 22 cpm
• Temp - afebrile
• SpO2 - 98%
• GRBS - 124mg/dl

Systemic Examination :

A. Cardiovascular system

• S1, S2 are heard

B. Respiratory system

• Has no dyspnoea and wheeze
• Has central trachea
• BAE +

C. Central nervous system

• Is conscious and speech is normal
• Had no signs of meningeal irritation
• Motor system -
         Tone - RUL - Increased
                     LUL - normal
                     LLL - Normal
                     RLL - increased
       Power - RUL - 3/5
                     LUL - 4+/5
                     LLL - 4+/5
                      RLL - 3/5
• Cerebral signs and gait - unable to test


D. Abdominal examination

• Shape of abdomen is scaphoid
• Has no tenderness, palpable mass
• Has no free fluid
• Liver, spleen are not palpable


Provisional diagnosis :

CVA WITH Rt. HEMIPARESIS
         WITH ACUTE HEMORRHAGE IN Lt. THALAMUS , CORONA RADIATA
        WITH OLD INFARCT IN Rt. THALAMUS AND B/L LENTIFORM NUCLEUS
         

Investigations :

On 23.10.21:






At 3pm
At 11:10 pm


Treatment :

• Inj. Mannitol 100ml/IV/BD
• Tab PCM 650 mg PD / SOS
•Inj. Pan 40 mg IV/OD
• Tab Amlong 5mg PO/OD
• Foleys catheterization
• Inj.  Optineuron 10amp in 100ml/NS/IV/OD
• Strict BP and PR monitoring 4th hourly
• Inform SOS
• Syp. Griuinctus BM
• Tab. Atorvas 40mg PO

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