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final practical examination : long case

Final practical examination : long case

A 53 year's old female with complaints of altered sensorium, weakness of right upper limb and lower limb                  

  Amit sharma
 HT. No. 1701006007

E-LOGS OF MEDICINE
"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"
A 53 year old female came with 
 altered sensorium ,difficulty in walking ,loss of speech ,weakness of right upper limb and right lower limb.

HOPI :
Patient was A known Case of Diabetes Since 11 Years and Hypertensive since 1 Year.
  She developed Giddiness which later Resolved on the Next Day.
RMP was called on and He prescribed Cinarizine and He also found that her BP was around 280 mmHg and gave Anti Hypertensive Drug(Telmisartan).
 On the next Day While she was going to washroom was unable to lift her leg and she was dragging her leg which was noticed by daughters so was brought to our Hospital .On her Way to Hospital She Couldn’t recognise her Daughters.
On Examination She Had Altered Sensorium ,Difficulty in Speaking,Weakness in Upper Limb And Lower Limb.
Daily Routine : She used To wake up At
 5: 30 am and would complete her Daily House Old Activities.
Negative History : No History of Headache,Fever,Vomiting ,Chest Pain,Palpitations and Shortness of Breadth.
Treatment History : For Diabetes -                           Metformin 500mg
For Hypertension :
Telma 40mg 
  Cilindipine 10mg 
Metoprolol 50mg
Personal History: 
Diet Mixed 
Appetite Normal,
  Bowel And Bladder Regular.
   Sleep Adequate 
No Allergies And Addictions.

Family History not Significant 
General Examination: 
Patient is Conscious, but not Cooperative and is oriented to Place and Person.
Moderately Built and Nourished.
Pallor :Absent
Icterus: Absent
Clubbing: Absent
Cyanosis :Absent
Lymphadenopathy :Absent
Edema:Absent
Vitals : 
Temperature - 100.8
Pulse 90 bpm
B.P 180/80mmHg
SpO2 94%.
SYSTEMIC EXAMINATION : 

CVS : S1 S2 heard, no murmurs

RS : Bilateral air entry present, normal vesicular breath sounds, no added sounds

GIT : Soft, non-tender, no organomegaly

CNS :

Dominance - Right handed

Higher mental functions
   
  • conscious

    • oriented to person and place

    • memory - able to recognize their family members

    • Speech - Broca's aphasia ( only comprehension, no fluency, no repitition) 

Cranial nerve examination 
   • 1 - couldn't be elicited

    • 2- Direct and indirect light reflex present

    • 3,4,6 - no ptosis Or nystagmus

    • 5- corneal reflex present  
    • 7- no deviation of mouth, forehead wrinkling present

   • 8- able to hear

   • 9,10- position of uvula couldn't be visualized

   • 11- sternocleidomastoid contraction present

     • 12- no tongue deviation

Motor system 

 Attitude - right lower limb externally rotated

Tone - Hypotonia on right side(both UL,LL)

            Normal tone on left side(UL,LL)

Bulk - Rt.                      Lt. 

 Arm 26cm.                26cm

Forearm 19cm          19cm

Thigh 42 cm.            42cm

Leg 28cm.                 28cm 
 Tricepsreflex
Ankle jerk reflex
Biceps Reflex(Right)

Tricepsreflex

 Knee Reflex(left)

Assessment of tone
Left lower limb


Upper limb tone

Ankle jerk reflex


Babinskis positive (rt side)

Babinski (left side)




POWER :

Sensory system : responding to pain

Cerebellar signs : couldn't be elicited
Diagnostic tests:
MRI


 


ECG

X RAY

TEMPERATURE


Medication








TREATMENT:
IV FLUIDS-NS @ 75 ml / hr

-RT. 100ml MILK WITH PROTEIN POWDER 8th hrly

 100ml water Every 2nd hrly

-ING.CITICHOLINE800mg /IV/IN 100 ml NS/BD


-ING.PAN40mg/PO/OD

-TAB. ECOSPIRIN 150mg /PO/HS

-TAB.ATORVAS40mg/PO/OD

-TAB.AMLONG 5mg /PO/OD

-ING .HUMAN ACTRAPID INSULIN ACC. TO GRBS CHECK

-TAB . DOLO 650mg SOS if temp>100F

-B.P. MONITORING 4th hrly











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