65 year old female

 A 65 year old female patient came to casualty with complaints of Involuntary movements of tongue, involuntary micturition and defecation since 2 days.

History of presenting illness:

Patient was asymptomatic 1 month ago. Then, she developed involuntary movement of tongue.

She had history of neck pain with back ache since 5 days. H/O vomitings since 2 days associated with nausea sensation, which was non bilious and non projectile.

Past History:

History of HTN AND DM present.

General physical examination:

Temp: afebrile

PR 90/min

RR 22 cpm

BP 130/70mmHg

SpO2 98%

Systemic examination:

CVS: S1 S2 +

RS: BAE+, NVBS +

CNS:

Patient is conscious, slurred speech 

 

Motor examination:                 

                      RIGHT                 LEFT

Tone :

UL                    incr                  incr

LL.                   incr.                 incr


Power:          

  

UL.                       4/5.              4/5

LL.                       4/5.               4/5


Reflexes:

Biceps                        +.       . +

Triceps.                     +.          +

Supinator.                +.          +    

Knee.                        +.          +

Ankle.                      +.          +

Plantar              Flexor.        Flexor 



Investigations:

Hemogram:

Hb 7.5 

TLC 11,000

PC 3.61

Na- 135, K - 3.7, Cl- 96


Random blood sugar



Serum electrolytes



Serum creatinine- 1.1



Blood urea - 33




Liver function test:


MRI


USG ABDOMEN:



Provisional diagnosis:

?CVA c ischemic stroke c Right side acute infarct in right frontal and parietal lobe ? Metastasis? Granuloma? Vasculitis?

Treatment:

Day 1:

Inj PAN 40mg IV/OD

Tab ASPIRIN 150mg/PO/OD

Tab CLOPIDOGREL 75mg/PO/OD/HS

Tab ATORVAS 40mg/PO/OD/HS

INJ HAI S/C , ACCORDING TO GRBS

INJ MANNITOL 100ml IV/BD

DAY2:

Inj PAN 40mg IV/OD

Tab ASPIRIN 150mg/PO/OD

Tab CLOPIDOGREL 75mg/PO/OD/HS

Tab ATORVAS 40mg/PO/OD/HS

INJ HAI S/C , ACCORDING TO GRBS

INJ MANNITOL 100ml IV/BD

DAY 3:

Tab PAN 40mg/PO/BD

INJ OPTINEURON 1amp in 100ml NS/IV/OD

Tab TETRABENAZINE 25mg PO/OD

INJ HAI ACCORDING TO GRBS

INJ ZOFER 4MG IV/SOS

INJ DEXA 8MG IV/BD

TAB LEVIPIL 500mg PO/BD

In view of ? Metastasis in brain, gynecology opinion taken in view of any pathology




DAY 4:

Tab PAN 40mg/PO/BD

INJ OPTINEURON 1amp in 100ml NS/IV/OD

Tab TETRABENAZINE 25mg PO/OD

INJ HAI ACCORDING TO GRBS

INJ ZOFER 4MG IV/SOS

INJ DEXA 8MG IV/BD

TAB LEVIPIL 500mg PO/BD

SYR CREMAFFIN PO/HS








Comments

Post a Comment

Popular posts from this blog

A YOUNG MALE REQUIRING GREAT EFFORT TO SQUAT..!!

Image
Let me Introduce myself , I am G.ACHAL RAM currently in final year pursuing MBBS.   My aim of this section is to do a comprehensive assessment regarding the  case provided by our interns. The whole clinical data including history, clinical features and workup is provided in the below link. https://hitesh116.blogspot.com/2020/05/12may-2020-elog-medicine-intern.html?m=1 After exploring the above case , the SUBJECTIVE COMPLAINTS are as follows : Weakness of bilateral lower limbs since 20 days Bilateral edema in lower limbs H/O Difficulty in maintaining posture in squatting position and getting up from that position H/O Difficulty in wearing and holding chappals. On reviewing the chief complaints , focused assessment  on CENTRAL NERVOUS SYSTEM , PERIPHERAL NERVOUS SYSTEM and MUSCULOSKELETAL SYSTEM must be on top priority to come up with a differential diagnosis and near possible provisional diagnosis. DETAILED HISTORY OF PRESENT ILLNESS WEAKNESS Weakness initially started in the proximal r
Read more

45 YEAR OLD FEMALE

Image
                                                     ELOG BASED CASE STUDY DATE: 24/08/21  A 45 year old lady came to Medicine OPD on 24/08/21 afternoon with the chief complaints of burning micturition, fever , pain in Right loin since 7 days , pain abdomen since 3 days , loose stools since 2 days  and SOB , nausea since 1 day. Patient was apparently asymptomatic 1 week ago. Then she developed burning micturition one week , not associated with increased frequency of passing urine and urgency. she also developed pain in the right loin. Inspite of the above symptoms, she went for planting mirchi in her farm. Later, after  couple of days she developed fever which was intermittent ( on and off ), relieved on medication. associated with loose stools. she is also complaining of breathlessness since one day( grade 2). Then, she was taken to outside hospital , treated symptomatically, dengue test was done and turned out to be positive and she was referred to our hospital in view of  decreased
Read more

1601006069 short case

Image
I'm a final year medical undergraduate bearing the hall ticket number-1601006069. I've been allotted with this following de-identified case to present on the day of the final practical exam, so I've contacted the patient and took the verbal consent to take the history and to examine the patient.  This E log also reflects my patient center’s online learning portfolio and valuable inputs on the comment box are welcome. A 46yr old female, housewife resident of Nalgonda came to the hospital with chief complaints of shortness of breath since 5days  History of present illness:   She was apparently asymptomatic 5days back then she developed shortness of breath which was insidious in onset, gradually progressive, aggravated on lying down, and relieved on medication. Associated with wheeze , paroxysmal nocturnal dyspnea Anasarca since 5days and cough with expectoration since 5days which is insidious in onset. Past History: K/c/o COPD since 12yrs. General examination: Raised JVP. Res
Read more