GM e-log

Hi all. This is Ramya, a  3rd year dental 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 ongoing case and will be updated as and when the information is provided.

A 75 year old male was brought to the casualty for further care for known case of CVA diagnosed 1 week back.

HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 10 days back when he observed deviation of mouth. associated slurring of speech not associated with drooling of saliva.The patient also complained about throat pain and difficulty in swallowing(solids and liquids equally) 10 days back for which Upper GI endoscopy was done(which showed no abnormality). This lead to the patient's reduced appetite. The patient also complained of generalised weakness since 10 days.

This was also associated with headache(diffuse) and approx. 12 episodes of vomitings lasting for 2-3 days 10 days back. The patient also complains of continuous hiccups since 3 days which gets intermittently relieved by itself.

The patient is a k/c/o DM 2 and HTN which was diagnosed 10 years back when the patient went to a local hospital for complaints of headache, giddiness and blurring of vision.

The patient is on Glycoryl, amlodipine and atenolol for the same.

N/k/c/o Thyroid disorders, BA, TB, Epilepsy. 

PAST HISTORY

There is H/O snake bite 6 yrs ago following which the attenders stated that the patient did not speak a word for the following 4 days


O/E : 

Pt is c/c/c, oriented to t/p/p

Vitals : 

Temp: 98.4 f

HR: 82 bpm

RR : 22cpm

BP : 130/90 mm hg

Spo2: 97 @ RA

GRBS :  500 mg/dl 


SYSTEMIC EXAMINATION : 


CVS : S1 S2  + . 

RS : BAE + NVBS + 

PA:Soft, non tender

CNS :  Tone :normal in all limbs 

            Power :4/5 in all limbs 

INVESTIGATIONS

CXR - Normal

MRI BRAIN

- Acute lacunar infarcts in left lateral aspect of medulla oblongata

- Chronic lacunar infarcts in bilateral lentiform nuclei

- Age related mild cerebral and cerebellar atrophic changes with chronic ischemic changes.

DIAGNOSIS : CVA


TREATMENT : 

IVF : NS , RL @ 100ml/hr 

INJ. HAI 6U IV/STAT

INJ.PANTOP 40mg IV/BD

INJ. OPTINEURON 1amp in 100ml NS IV/BD

Tab. ECOSPRIN 150mg po/od

Tab. ATORVAS 40mg po/hs

Tab. GLOPITAB 150mg po/odI




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