General medicine case presentation 6

 This is an online Elog book to discuss our patients 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 clinical problems with collective current best evidence based inputs.


A 75 years old male patient came to casuality with the chief complaints of 


1) sudden onset of weakness in right upper limb & lower limb


 2) Deviation of mouth to the left.


3) Slurring of speech.


4)cough with sputum since 10 days.


HISTORY OF PRESENT ILLNESSES:-


Patient was apparently asymptomatic 2 days back, yesterday while he was taking his tea at 7 pm he noticed sudden weakness in his right upper & lower limb, deviation of mouth towards left and Slurring of speech.He phoned to his attenders ,upon their arrival his upper limb weakness was resolving & on bringing him to the hospital deviation of mouth resolved.


PAST HISTORY:-


He is a known case of diabetes & hypertension since 11 yrs and is on regular medication.


He had sudden onset of SOB & chest pain 10 years back and diagnosed as MI underwent PTCA ( percutaneous transilluminal coronary angioplasty)and is on Tab.Atorva 20 mg 100 pills medication till now.


Patient was a chronic cigar smoker for 40 yrs and stopped after PTCA.


Never visited the hospital except for regular diabetic checkup.


PERSONAL HISTORY:-


DIET:-mixed


APETITE:-normal


BOWEL movements:- normal


MICTURITION:-normal


Addictions:-


Chronic smoker for the past 40 yrs and stopped 10 yrs back.


No significant family history.


TREATMENT HISTORY:-


Patient is not allergic to any drugs.


GENERAL EXAMINATION:-


patient was coherent, cooperative and conscious.


Patient looks thin and weak.


No cyanosis,pallor, icterus, clubbing,lymphadenopathy.


VITALS:-


Temperature:- afebrile


SpO2:-97% at room air


Pulse rate:- 78/ min


Respiratory rate:-16 cpm


Bp:-150/100 mm Hg


SYSTEMIC EXAMINATION:-


CVS:-


S1&S2 heard


No murmurs.


RS:-


Treachea:- Central


No dysponea


No wheeze


Abdomen:-


Shape of abdomen:-scaphoid


Tenderness:-no


Liver:- not palpable


Spleen:- not palpable


CNS:-


Speech:- slurred


Cranial nerves:- normal


Motor nerves:-tone increased in right upper and lower limbs.


Sensory system:- normal


PROVISIONAL DIAGNOSIS:-


? Acute Mi

UMN facial palsy 

Hemiparesis ( resolved)

INVESTIGATIONS:-

HEMOGRAM:-


BLOOD GLUCOSE LEVELS:-



GLYCATED HEMOGLOBIN:-


RENAL FUNCTION TEST:-


LIVER FUNCTION TEST:-


TREATMENT:-  

Tab enalapril 5mg/po/OD 

Tab Atorvas 40mg /po/ h/s 

Tab Ecospirin 150mg /po/OD 

Tab Glimiperide 1mg 

Metformin 500mg /po/OD 

GRBS monitoring 6th hourly 

Syrup Ascoryl 10ml

Tab Clopidogrel 75 mg /po/ h/s 








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