General medicine elog 2

Name: M.YASHWITHA 
Roll.no:73

Greetings to one and all who are reading my blog .This is M.Yashwitha 3rd semester.
This is an online E log platform to discuss case scenarios of a patient with their guardian's permission.
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 treatment plan.
Case discussion:
 75 years old male patient came with a complaint of left sided weakness and deviation of mouth to right side.
 He had hypertension and Diabetes mellitis (since 8 years).
-patient was apparently asymptomatic uptill 5pm ( 17/7/21).
•At 5pm: could not hold the tea cup with his hands and spilled it all over him. Following which his wife applied lotion over his abdomen and they had dinner and watched TV. 

•At 2 am: He called his wife because he couldn't move his left UL and he couldn't talk properly and there was deviation mouth to the Right. He couldn't contain his urine his wife recollect.( he arrived to the hospital with Foley's )

•At 5 am: went to local hospital which diagnosed him with Left UL Monoplegia with Right sided UMN palsy.
 CT scan was done.
•At 9 am: patient arrived at our hospital.His complaints were the above but we also noticed that he had Left LL weakness .Could swallow water when given in bottle caps.

•At 8 pm: Above complaints + decreased ability to swallow -RT was inserted.
•No h/o fall or trauma,fever,epilepsy .
-H/o stopping his medication given for HTN 15 days ago (reason not clear).
-No h/o similar complaints in past .
•Ocassionally consumed toddy,does not smoke /consume tobacco or bleedi.
*Diet:mixed.
-Appetite: normal.
-Sleep:normal.
-Bowel and bladder:has not passed stools since yesterday (16/7/21).

General Examination:
Patient was conscious ,coherent,and cooperative .He was oriented to time,place and person.Moderately built and nourished.

-No pallor,interus, cyanosis,Lymphadenopathy.

Vitals:
Afebrile
BP 160/100
PR 80
RR 16
Spo2 96%
GRBS 126.

Respiratory sydtem: BAE+,NVBS heard ,Trachea central.

CVS: S1 S2 Heard ,No murmurs.

Abdomen: Soft and non tender ,Bowel sounds heard.

CNS:
•Cranial nerves-Normal except deviation of mouth to RT side and inability to shrug the left shoulder .Recently decreased ability to swallow .
•Sensory system: Normal.
•Motor system:
-Power:decreased in LT UL and LL.
-Tone: decreased in LT UL and LL.
-Reflexes:
                   RT.              LT.
B               2+                2+
T                2+               2+
S                2+               2+
K                3+               3+
A                1+              1+
Plantar   Flexor.       Extensor.
•Provisional Diagnosis:
CVA; LT Hemiparesis 2° to ? Acute infract in Rt internal capsule Rt MCA territory .

•Plan of management:
Admitted in AMC and following investigations were sent CBP,RFT,FLP,RBS,HbA1c,CXR PA view.

•Treatment:
1.T.ECOSPIRIN 150 MG OD/RT.
2.T.CLOPITAB 75 MG OD/RT.
3.Inj.Optineuron 1amp in100 ml NS OD / i.v.
4.T.PAN 40 MG OD/RT.
5.T.ATORVAS 40 MG OD/RT.
6.RT FEEDS-100ml WATER HOURLY and 200 ml Milk 4th hourly W/O Sugar.
7.inj .HAI s/c TID after GRBS .
8.BP/PR/SpO2/Temp monitoring.

Thank you!

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