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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
A 64 year old male patient resident of choutuppal came to casuality with chief complaints of
- unable to talk since 8 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 8 days back then developed loose stools 5 episodes per day for 1 day then the attenders took to nearby doctor which then subsided on medication.He also developed hiccups on the same day.When the attenders noticed loss of speech they were advised to go for higher centre.
Daily routine:-
He wakes up around 8 am and eats breakfast around 8:30 am and lunch around 12:00 pm and dinner at 8:00 pm
PAST HISTORY:-
-He is a known case of type-2 diabetes mellitus since 6 yrs and he is on medication
-Tab.Metformin OD ,Tab.Glimiperide OD
-History of jaundice 2 years back
-No history of hypertension,asthma,epilepsy,CAD
PERSONAL HISTORY:-
Before 6 years he used to work as cattle rearer . He stopped working since 3 years and he uses stick to walk as he is unable to walk properly since 3 years.
Appetite - lost
Diet - Mixed
Sleep - adequate
Bowel and bladder movements - irregular
Addictions: Occasional alcoholic and tobacco chewing daily .
Allergies : No allergies .
FAMILY HISTORY :-
His daughter had TB 7 years back and treated
His mother had TB 5 years back and treated
GENERAL EXAMINATION:-
Patient is conscious ,incoherent , uncooperative
Moderately Built and Moderately Nourished .
Pallor : present
Icterus : absent
Cyanosis: absent
Clubbing : absent
Lymphadenopathy : absent
Edema : absent
Vitals :-
Temp: Afebrile
BP : 100 / 50 mmHg
PR : 120 bpm
RR : 16 cpm
SYSTEMIC EXAMINATION:-
CNS examination :-
State of consciousness : decreased consciousness
Speech : incoherent
GCS-
E4V1M1
Sensory system :-
Pain - No response
Touch- fine touch - no response
crude touch - no response
Temp - no response
Vibration - no response
Joint position - absent
Cranial nerves : intact
Right Left
Tone :- UL hypo hypo
LL Hypo hypo
Power :- UL and LL not movement even with pain
Reflexes :-
Biceps + +
Tricep s + +
Supinator + +
Knee +
Ankle. ++
Brain stem reflexes
Conjunctival, corneal, pupillary +
Finger nose in coordination - no
Heel knee in coordination - no
CVS : S1 S2 + ,no murmurs ,no thrills
Respiratory System : decreased air entry on left side . Crepts are heard. Position of trachea - central.
Per abdominal examination:-
Soft , non tender , no signs of organomegaly .
PROVISIONAL DIAGNOSIS:-
Altered sensorium secondary to meningoencephalitis
- Left sided pneumonia ( ?TB )
- bilateral fixed flexion deformity since 2 yrs
TREATMENT :-
1) IVF 0.9 %NS IV @ 100 ml / hr
2) Nebulization with duolin - 8th hrly , budecort - 12 th hrly
3) Inj .Thiamine 200 mg IV/BD in 100 ml NS
4) Inj . Dexa 6 mg IV / TID
5) ATT therapy PO/OD FDC:3 tab/ day
6) GRBS monitoring 6 th hrly
7) vitals monitoring 6 th hrly
8) Temp monitoring 4 th hrly
9) Inj H. Actrapid insulin SC TID acc to GRBS
10)RT Feeds - 100 ml milk +3-4 scoops protein powder 4 th hrly , 50 ml H2O 2nd
hrly
11 ) physiotherapy was done .
INVESTIGATIONS
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