case 11 - 75 YRS OLD MALE WITH CVA

 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 patient's 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 the comment box is welcome.

Team:

Interns-

M Supriya

Mohitha

K Sowmya

Sanjay

Amrutha


Dr.Druga Krishna PGY1

Dr.Ajith Kumar PGY2

Dr.Laxma Reddy PGY3

Dr.Manasa PGY3

Dr.Vijaya Lakshmi (Ast.Prof.)

C / o altered sensorium 
Unable to speak
Unable to move her upper and lower Limbs since  6 o'clock in the evening yesterday
Patient had history of toddy intake in the afternoon yesterday after which she unable to move her right upper limb and lower Limbs ⁶6ťshe unable to speak ok or response two daughters commands six o'clock in the evening yesterday then she was taken to to local Hos6pital where inhalation and cough syrup was given following which she was referred to KIMS for further evaluation
Past history
No  H/ o DM,HTN,CVA,ASTHMA,76TB,EPILEPSY 
Personal history 
 Toddy drinker daily
-General examination:-
pt was unconscious
pt was thin built 



No signs of Icterus, cynosis,clubbing lymphedenopathy, Generalized edema 
GCS:-E1V1M5
CNS-
Higher mental functions-cant be elicited 
Cranial nerves-cant be elicited
motor system-.                    R.                      L.   
power                  UL-.          1/5.              4/5.    
                            LL-.           2/5.              4/5.  
 Tone-.                 UL-.     Hypotonic      Hypertonic
                            LL-.       Hypotonic      Hypertonic
reflexes-.                                   R.                      L.   
                biceps-.                     1+.                   1+.  
                triceps-.                    -                      -
                supinator-.                -                       -
                knee.                          -                      1+
               ankle-.                         -                        -
               plantar -          extension             extension












Sensory system-cant be elicited 
Cerebellar functions-cant be elicited  
Cvs:-s1,s2+

R/s:-BAE+
P/A:-soft,no organomegaly 







Treatment:-
On the day of admission 
1.inj.CEFTRIAONE 1gm/IV/BD
2.inj.OPTINEURON 1amp in 100ml NS/IV/OD
2.inj.PAN 40mg IV/OD
DAY 2
1.TAB ASPIRIN 75MG OD/PO
2.TAB ATORVASTATIN 40MG OD H/S
3.INJ.CEFTRIOXONE 1GM IV/BD
4.INJ.PAN 40 MG IV/OD
5.INJ OPTINEURON 1 AMP IN 100ML NS IV/BD
Day 3

1.TAB ASPIRIN 75MG OD/PO
2.TAB ATORVASTATIN 40MG OD H/S
3.INJ.CEFTRIOXONE 1GM IV/BD
4.INJ.PAN 40 MG IV/OD
5.INJ OPTINEURON 1 AMP IN 100ML NS IV/BD
pt was shifted to air bed to prevent bedsores

Patient was discharged with little or no useful function, effectively limiting rehabilitation.

Online : 
Patient wa bed ridden and expired in home due to aspiration ( sudden breathless after feed )

Comments

Post a Comment

Popular posts from this blog

DISSERTATION 2020-2022.

Image
DISSERTATION  Dr. Saicharan Kulkarni pgy1 ( 2020 ) TITLE OF THE TOPIC :   CLINICO-RADIOLOGICAL PROFILE, RISK FACTORS AND OUTCOMES IN PATIENTS WITH MOTOR WEAKNESS BRIEF RESUME OF THE INTENDED WORK Problem Representation  1)The repercussions of paralysis/weakness are enormous, both personally to the individual and to their family; and have huge economic costs to society. Paralysis takes many forms with multiple disorders causing paralysis, and multiple body systems often affected. (1,)   2) Motor learning is considered crucial for rehabilitation in general. In stroke, motor learning does not refer to the acquisition of new skills, but to the re-learning process of a previously acquired movement pattern .(2)   3) 3.  Though both clinical evaluation and MRI are complimentary in detection and precise localization of the level of lesion in patients with cervical myelopathy, there is paucity of data comparing segment specific clinical features with the MRI abnormalities in cervical myelopath
Read more

65M with Recurrent CVA with visual hallucinations and k/c/o pulmonary Koch’s

Image
 A 65-year-old male patient with known case of recurrent CVA presented with complaints of seen the faces, increased appetite and urinary incontinence since 2 months Visual Hallucinations are sudden in onset associated with the ringing sensation in ears and hearing voices from surroundings Patient was apparently a symptomatic six years back then he developed generalised weakness and giddiness for which he went to local doctor and diagnosed with diabetes and on OHA, then few months later he diagnosed with hypertension and on atenolol 50mg since 3yrs History of first CVA attack 5 years back for which she went to hospital and managed conservatively and on dual antiplatelet TS for few weeks. Then 4 years back he developed low-grade fever associated with productive cough and generalised weakness. For which he was diagnosed with pulmonary tuberculosis and on ATT for 6 months. Then he developed second attack of CVA 8 months back for which he took some herbal medication for 3 months and recover
Read more

Case 27 15 yr boy with Paraplegia and a history of Fever

Image
  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 patient's 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 the comment box is welcome. Here is a case i have seen: A 15 year old boy presented to the Opd at 2pm with the complaints of Slippage of footwear since 6 months Difficulty in walking since 6 months  Difficulty to get up from bed since 6 months Patient is in his 8th grade at a government school at a local village.  His parents work as Masons at a local village. He has an elder brother who is studying degree and a younger sister who is in her 10th grade. He was apparently completely alright 6 year
Read more