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I've 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 a diagnosis and treatment plan.
Name : Kattekola Sathwik
Roll no : 58
2017 batch
Case details
History
This is a case of 61 year gentleman hailing from rural area of nalgonda district
About 10 days ago .....
He came from farmland and had his dinner
Suddenly there was a seizure like activity where he had involuntary movements of all limbs, froth from mouth, shortness of breath and also had abdominal distention. The attender had also given the history of passing urine during the seizures.Then he became unconscious.
He was admitted in a private hospital where in they diagnosed it as seizures and also informed the attendent that he has a clot in the brain
For three days he was unconscious..
After gaining consciousness he recognised his family members and he was discharged yesterday .
The attendant complained that the patient looked *dull* and *weak* and also having breathlessness. His speech was also not understandable ( slurring of speech)
(Attendant also complained of movements of right upper limb and right lower limb when the patient was unconscious)
With this complaint the patient has been presented to the casualty.
Past history
Patient fell unconscious and then for 15 days he had limb weakness and giddiness
Recovered after 15 days
And he was diagnosed as hypertensive then
He was on medication for an year and then he abruptly stopped it...
Denovo diagnosis of Diabetes mellitus
Personal history
He is a chronic alcoholic for 20 yrs takes about 360 mL of whiskey per day. Also consumes toddy.
General examination
The patient is drowsy
He is weak
No pallor icterus cyanosis clubbing lymphadenopathy and pedal edema
Vitals :
Afebrile
Pulse : 134beats/minute
BP: 170/100 mmHg
RBS :300 mg/dL
SpO2 : 86 % at room air
Respiratory system examination
On auscultation bilateral coarse crepts were heard
Central nervous system examination
He is drowsy
No signs of meningeal irritation
Slurring of speech +
Glasgow coma scale E4V2M4
Reflexes Right. Left.
Biceps. 3+ 3+
Triceps. 3+ 3+
Supinator. . + +
Knee. 3+ 3+
Ankle 3+ 3+
Investigations
ECG
Imaging
X ray chest
On 30/09/2021
Seizures secondary to an Intracranial bleed
With atypical pneumonia
K/c/o hypertension since 5 years
K/c/o diabetes (Denovo)
Treatment
Date 30/9/2021
* Head end elevation
* O2 inhalation to maintain spo2 >94%
* TAB. CLINDAMYCIN 200 mg TID
* TAB PARACETAMOL 650MG. TID
* TAB STAMLO 50 MG RT/OD
* TAB LEVIPIL 500 MG. RT/TID
* TAB PULMOCLEAR RT/OD
* Inj. CIPROFLOXACIN 500 mg i.v. OD
* TAB PREGABA-M RT/SOS
* NEB with IPRAVENT 2nd hourly
* NEB with BUDECORT 4 th hourly
* Frequent change of posture
* Chest physiotherapy
* Monitor vitals 4 th hourly
* I/O and temperature- 4 th hourly
* GRBS -6th hourly
* Inj. HAI s/c according to sliding SCME
At 6pm
Patient was lying down appears to be drowsy and aurosable speaking in syllables
Date :01/10/2021
Assessment
Temperature:100.7 F
BP 120/80 mmHg
Pulse rate :104/min
CVS : s1 s2 present
RS : BAE +. NVBS & B/L ADDED SOUNDS
CNS : E4 V2 M4
Power : 3/5 in both. The limbs
Tone is increased in both the limbs
Reflexes
Right. Left
B. 2+. 2+
T. . 1+ 2+
S. 1+. 1+
K. 3+. 3+
A. . 1+. 1+
P. Ext. Ext.
Pupils: sluggish reaction to light
Treatment:
*Head and elevation
* Continued oxygen inhalation to maintain the spo2
* Ryles tube feeds with hundred ml of water 2nd hrly and 400 ml of milk 4th hrly
*Inj. LEVOFLIXACIN 500MG OD. IV
*INJ. HAI. S/C. 8am -1 pm -8 am
*Tab. CLINDAMYCIN 300 mg RT TID
*Tab. PCM 650 MG RT TID
*TAB STAMLO 50 MG RT/OD
* TAB LEVIPIL 500 MG. RT/TID
* TAB PULMOCLEAR RT/OD
* TAB PREGABA-M RT/SOS
* NEB with IPRAVENT 2nd hourly
* NEB with BUDECORT 4 th hourly
*Frequent change of posture
*Chest physiotherapy
* Monitor vitals 4 th hourly
* I/O and temperature- 4 th hourly
* GRBS -6th hourly
Date :02/10/2021
Assessment
Temperature:98 F
BP 110/100 mmHg
Pulse rate :84/min
CVS : s1 s2 +
RS : BAE +.NVBS
CNS : E4 V2 M4
Power : 3/5 in both. The limbs
Tone is increased in both the limbs
Reflexes
Right. Left
B. 2+. 2+
T. 1+ 1+
S. 1+. 1+
K. 3+. 3+
A. 1+. 1+
P. Ext. Ext.
Treatment:
*Head and elevation
* Continued oxygen inhalation to maintain the spo2
* Ryles tube feeds with hundred ml of water 2nd hrly and 400 ml of milk 4th hrly
*Inj. LEVOFLIXACIN 500MG OD. IV
*INJ. HAI. S/C. 8am -1 pm -8 am
*Tab. CLINDAMYCIN 300 mg RT TID
*Tab. PCM 650 MG RT TID
*TAB STAMLO 50 MG RT/OD
* TAB LEVIPIL 500 MG. RT/TID
* TAB PULMOCLEAR RT/OD
* TAB PREGABA-M RT/SOS
* NEB with DUOLIN 2nd hourly
* NEB with BUDECORT 4 th hourly
*Frequent change of posture
*Chest physiotherapy
* Monitor vitals 4 th hourly
*I/O and temperature- 4 th hourly
* GRBS -6th hourly
Date :3/10/2021
Assessment
Temperature:98 F
BP 110/100 mmHg
Pulse rate :84/min
CVS : s1 s2 +
RS : BAE +.NVBS
CNS : E4 V2 M4
Speech : incoherent words
Awake
Spontaneous eye opening
Obeying commands for movement
Power : 3/5 in both. The limbs
Tone is increased in both the limbs
Reflexes
Right. Left
B. 2+. 2+
T. 1+ 1+
S 1+. 1+
K . 3+. 3+
A. 1+. 1+
P. Ext. Ext.
Treatment:
*Head and elevation
* Continued oxygen inhalation to maintain the spo2
* Ryles tube feeds with hundred ml of water 2nd hrly and 400 ml of milk 4th hrly
*Inj. LEVOFLIXACIN 500MG OD. IV
*INJ. HAI. S/C. 8am -1 pm -8 am
*Tab. CLINDAMYCIN 300 mg RT TID
*Tab. PCM 650 MG RT TID
*TAB STAMLO 50 MG RT/OD
* TAB LEVIPIL 500 MG. RT/TID
* TAB PULMOCLEAR RT/OD
* TAB PREGABA-M RT/SOS
* NEB with DUOLIN 2nd hourly
* NEB with BUDECORT 4 th hourly
*Frequent change of posture
*Chest physiotherapy
* Monitor vitals 4 th hourly
*I/O and temperature- 4 th hourly
* GRBS -6th hourly
DATE-04/10/21
Assessment
S- pt is drowsy
Objective:
Pt is drowsy
Afebrile
PR:96 bpm
BP: 130/90 mmHg
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
ASSESSMENT-
? Seizures secondary to Intracranial bleed ,
?Atypical Pneumonia ,
With k/c/o HTN
Denovo DM
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.levofloxacin 500 mg iv/od
4)INJ.hai s/c tid
5)Tab.PCM 650 mg RT/TID
6)Tab.Levipil 500mg RT/TID
7)TAB.PULMOCLER RT/OD
8)TAB.Clindamycin 300mg/RT/TID
9)TAB.LEVIPIL 500 Mg RT/TID
10)Tab.Stamlo 5mg/PO/OD
11)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
12) Monitoring vitals 4th hrly
13) GRBS charting 6th hrly
14)I/O and Temperature charting
15) Chest physiotherapy
Date -05/10/21
Assessment
S- pt is drowsy
Objective:
Patient is drowsy
Afebrile
PR:100 bpm
BP: 110/90 mmHg
GRBS:161 mg/dl
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
ASSESSMENT-
1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic foci in bilateral cerebellar hemisphere,brainstem ,basal gangilia
2- seizures secondary to CVA .
3- Aspiration pneumonia
4- Denovo diabetes
Plan of care:
1)Head end elevation
2) O2 inhalation to maintain Spo2 >94%
3)INJ.hai s/c tid
4)Tab.PCM 650 mg RT/TID
5)Tab.Levipil 500mg RT/TID
6)TAB.PULMOCLER RT/OD
7)TAB.Clindamycin 300mg/RT/TID
8)TAB.LEVIPIL 500 Mg RT/TID
9)Tab.Stamlo 5mg/PO/OD
10)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
11) Monitoring vitals 4th hrly
12) GRBS charting 6th hrly
13)I/O and Temperature charting
14) Chest physiotherapy
Date -06/10/21
Assessment
S-pt is drowsy
Objective:
Pt is drowsy
Afebrile
PR:74 bpm
BP: 100/60 mmHg
GRBS:219 mg/dl
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
ASSESSMENT-
1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic foci in bilateral cerebellar hemisphere,brainstem ,basal gangilia
2- seizures secondary to CVA .
3- Aspiration pneumonia
4- Denovo diabetes
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.levofloxacin 500 mg iv/od
4)INJ.hai s/c tid
5)Tab.PCM 650 mg RT/TID
6)Tab.Levipil 500mg RT/TID
7)TAB.PULMOCLER RT/OD
8)TAB.Clindamycin 300mg/RT/TID
9)TAB.LEVIPIL 500 Mg RT/TID
10)Tab.Stamlo 5mg/PO/OD
11) Syrup Ascoril
12)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
13) Monitoring vitals 4th hrly
14) GRBS charting 6th hrly
15)I/O and Temperature charting
16) Chest physiotherapy
Date-07/10/21
Assessment
AMC - 1st BED
S- pt is drowsy
Objective:
Pt is drowsy
Afebrile
PR:70 bpm
BP: 120/70 mmHg
GRBS:137 mg/dl
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
ASSESSMENT-
1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic foci in bilateral cerebellar hemisphere,brainstem ,basal gangilia
2- seizures secondary to CVA .
3- Aspiration pneumonia
4- Denovo diabetes
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.levofloxacin 500 mg iv/od
4)INJ.hai s/c tid
5)Tab.PCM 650 mg RT/TID
6)Tab.Levipil 500mg RT/TID
7)TAB.PULMOCLER RT/OD
8)TAB.Clindamycin 300mg/RT/TID
9)TAB.LEVIPIL 500 Mg RT/TID
10)Tab.Stamlo 5mg/PO/OD
11) Syrup Ascoril
12)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
13) Monitoring vitals 4th hrly
14) GRBS charting 6th hrly
15)I/O and Temperature charting
16) Chest physiotherapy
Date -08/10/21
Ward case
Assessment
S-pt is drowsy
Objective:
Pt is drowsy
Afebrile
PR:96 bpm
BP: 120/80 mmHg
GRBS:120 mg/dl
CVS: S1, S2 heard
RS: BAE present ,B/L coarse crepts present in all areas
P/A: soft ,non tender ,bowel sounds present
CNS: E4V2M4
Tone : normal b/l
Reflexes:
Lt. Rt
B. 3+. 3+
T. 3+. 3+
S. 1+. 1+
K 3 +. 3+
A. 3+. 3+
ASSESSMENT-
1- Acute CVA - ( acute hemorrhagic infarct ) - Right temporal lobe hemorrhage .with tiny hemorrhagic foci in bilateral cerebellar hemisphere,brainstem ,basal gangilia
2- seizures secondary to CVA .
3- Aspiration pneumonia
4- Denovo diabetes
Plan of care:
1)Head end elevation
2)O2 inhalation to maintain Spo2 >94%
3)INJ.hai s/c tid
4) Tab. Azithmol RT/OD
5)Tab.PCM 650 mg RT/TID
6)Tab.Levipil 500mg RT/TID
7)Tab.Stamlo 5mg/PO/OD
8) TAB prega M 25mg/RT/H/S
9)Nebulization with Budecort 6th hrly
Ipravent 2nd hrly
10) Monitoring vitals 4th hrly
11) GRBS charting 8th hrly
12)I/O and Temperature charting
Planning for discharge
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