75 year old male with involuntary movements of upper and lower limbs
DATE: 22 July 2022
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
CASE:
A 75 year old male patient from pochampally farmer by occupation presented to the opd with chief complaints of involuntary movements of both upper and lower limbs from 3 days
HOPI:
Patient was apparently asymptomatic 5 months back then he had loss of vision 5 months back , they went to a hospital in Hyderabad where he was diagnosed with stroke and managed promptly with some medications.15 days back he fell unconscious and again went back to that hospital and was found to have Hypertension for which he is on medication. He had involuntary movements of both upper and lower limbs 3days back which was associated with involuntary micturation and post ictal confusion. He also had altered sensorium. He had 3 episodes 1st episode was on 19th 11am and 2 days back he had 2 more episodes. No history of fever, vomitings, headache, Loss of consciousness.
Daily routine:
He usually wakes up at 4am and goes for a walk and has breakfast by 10 am and goes to farm and around 1 pm he has lunch and has dinner by 6pm and sleeps by 7pm. 3 days back in the morning he had an episode of involuntary movements while walking and felt like he was about to fall and sat on a chair then he came to the hospital.
PAST HISTORY:
K/c/o cerebrovascular accident 5 months back.
K/c/o Hypertension from 15 days for which he is on medication(unknown).
He is not a known case of diabetes mellitus, asthma, tuberculosis, CAD.
History of injection into the right knee joint for knee pain 10 years back.
PERSONAL HISTORY:
Diet-mixed
Appetite - decreased
Sleep-adequate
Bladder movement- regular
Bowel movements- once in 2 days
He used to drink alcohol occasionally (twice a month) and he was a smoker (1 pack of bediper day) since 20 years. He stopped drinking alcohol and ceased smoking from 6 months.
FAMILY HISTORY:
Not significant.
GENERAL EXAMINATION:
Patient is conscious,coherant, cooperative.
He is moderately built,and poorly nourished.
Pallor- absent
Icterus- absent
Cyanosis absent
Clubbing- absent
Generalised lymphadenopathy-absent
Bilateral pedal edema- absent
Vitals:
Temperature-98.5 degree F
Pulse rate-89 bpm
Blood pressure-120/70 mmhg
Respiratory rate- 22cpm
Spo2-98%
GRBS-178mg/dl.
SYSTEMIC EXAMINATION:
Central nervous system:
Oriented to time,place,person
Memory : recent, remote intact
Speech: normal
Cranial nerves:
1-intact
2- vision: decreased vision
colour vision:normal
3,4,6- normal(no restriction of movements of eye)
5-normal( muscles of mastication+sensations of face)
7-normal
8- didn't elicit
9,10,11,12-normal
Motor- tone -normal
Power- 5/5 in b/l lowerlimbs 5/5 in upper limbs
Reflexes:
biceps:b/l:2+
triceps:2+
supinator+2
knee:2+
plantars:b/l flexor
sensory: crude ,pain,temp, fine touch, joint position, proprioception are normal in all dermatomes.
Cardiovascular system: s1 s2 heard and no murmurs heard
Respiratory system: normal vesicular breath sounds-heard, Bilateral air entry-present ,
Abdominal system: soft and non tender, no Hepatomegaly, spleen is not palpable.
TREATMENT:
Inj. LEVIPIL 500mg I.v BD
Inj. PIPTAZ 4.5g Iv TID
Inj. PANTOP 40mg I.v OD
Tab AZEE 500mg PO OD
Inj. LORA 2cc I.v SOS
Inj. ZOFER 4mg I.v SOS
Inj. OPTINEURON IN 500 ml NS 1 amp I.v OD.
Comments
Post a Comment