Varshitha’s ELOG
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 68 year old male was brought to the hospital by his attenders(son) with the complain of giddiness since 3 days,inability to use his right upper and lower limb since 2 days
HISTORY OF PRESENT ILLNESS- Patient was apparently asymptotic 6 months back , then he developed giddiness ,immediately after waking up from bed, he had such episodes ocassionaly for which one day they took him to rmp,where he was diagnosed with high blood pressure for which they gave the patient- Telma am tablets,even after using these,the symptoms did not subside and 5 days back on monday- when the patient had similar complain of giddiness,they took him to rmp again where the patient’s blood pressure was recorded as low bp(not known ) for which the rmp gave him tablets(not known) On tuesday after having breakfast the patient went to sleep and after two hours when he woke up he was unable to use his right upper and lower limb for which he was brought to the hospital on thursday(23/07/2020)
Past history
k/c/o htn- 6 months - for which he is using telme am tablets
Not a k/c/o asthma, epilepsy,jaundice
Personal history
He is a chronic smoker since (45 years)
Family history
Drug history - herbal medications for DM since 15 years, Htn since 6 months-telme am tablets
(40+5mg)
GENERAL EXAMINATION-
Patient is consious , coherent,cooperative
moderately built and nourished,
Vitals- temp- afentile BP- 110/70 mmhg , PR - 60 bpm, with missed beats(approx 4) in a minute,normal volume and character
RR- 17cpm,
CNS examination
Higher mental functions- patient is conscious,
speech- in comprehensive speech- fluency not intact, bt patient is able to obey commands ,
Motor system-
bulk- Rt UL.
tone- hypotonia in all four limbs
power- RT UL.
Reflexes-
Triceps reflex
Biceps reflex.
supinatorreflex
knee reflex
ankle reflex
plantar reflex
sensory system- intact ,
cranial nerve examination- 3,4,5,6,8,11,12 intact
7the nerve- mouth deviated to left side and loss of nasolabial fold on right side,remaining cranial nerves could not be elicited
Respiratory system- shape of the chest- normal,
position of the trachea- midline, B/l air entry present, no added sounds
1) ACUTE LEFT MCA INFARCT.2) HF (EF 45%) sec to NSTEMI/HTN/?COPD.3) K/C/O DM ,HTN,SMOKER.
TREATMENT
Tab. Clopitab 75mg PO OD
Inj. HAI S/C according to S/S before meals
syrup Potchlor 15ml/P/O B/D in 100 ml of water
Inj manitol 100ml/Iv/TID.
Head end elevation
physiotherapy of RT UL and LL
Monitor BP,temp 4th hourly pulse and spo2 hourly monitoring ,grbs charting 6th hourly
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