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-centred online learning portfolio and your valuable comments on comment box is welcome.
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.
Case
This is a case of a 45 year old Male admitted in the ward, with a complaints of
- Breathlessness on & off since 20 days
- Weakness of Right upper and lower limbs since 3 hrs
- Unable to speak since 1 hr
History Of Presenting illness:
Patient was apparently asymptomatic 10 years back and devloped weakness of RT. upper and lower limb for which they visited KIMS nkp and was managed conservatively and was diagnosed with DM (type -2) and has been on OHAs since then.
Now since 20 days pt. Is having breathlessness which is intermittent for which he want to local hospital diagnosed with consolidation of Right middle lobe . He tested CB-NAAT -ve, and managed conservatively.
On 14th December, at around 9 pm Pt. Started developing weakness of Rt. UL and LL and was unable to speak since 1 year.
No h/o headache , seizure........
Pt. Mention that he did not take his Diabetes medicine yesterday .
History of Past illness:
K/c/o D.M. type 2 since 10 years ( on Tab. Glimy M2)
Not a k/c/o HTN, asthma, CAD, T.B. ...
Personal history-
Occupation:- Farmer(tractor drivers)
Married
Diet- mixed
Apetite- Normal
Seep- adequate
Bowel and bladder movements:- regular
Addictions:- Alcohol occasionally
No other addictions
Family history
No Similar Complaints in the family
Allergic history
No known allergies
General examination
Pallor : no
Icterus: No
Cyanosis :no
Clubbing of fingers/toes : No
Lymphadenopathy : No
Edema of feet : No
Malnutrition : No
Temp. : 98.6 F
P.R. : 112 bpm
R.R. : 16 cpm
B.P. : 100/80 mmhg.
SYSTEMIC EXAMINATION
CVS
Cardiac sounds :- S1 & S2 - Present
Cardiac murmurs :- NO
RESP. SYSTEM
Dyspnoea :Yes
Wheeze : No
Position of Trachea : Central
Breadth Sounds : Vesicular
ABDOMEN
Shape of abdomen : Scaphoid
Tenderness : NO
Palpable Mass : NO
Bruit:- No
Liver : Not Palpable
Bowel sounds: Yes
C.N.S
Level of consciousness : Consciousness: Conscious / Alert
Speech : Slurred
Signs of Meningeal irritation a)Neck stuffiness: NO b)Kernig's sign: NO
R ight. Left.
Tone.
UL. Normal. Normal.
LL. Normal. Normal
Power
UL. 1/5 5/5
LL. 1/5 5/5
Reflexes.
Biceps:. 1+. 2+
Triceps. 1+. 2+
Supinator. -. 1+
Knee. 1+. 2+
Ankle. -. 1+
INVESTIGATIONS:
Provisional Diagnosis:-
Right Hemiplegia. 2° to ? Acute ischemic stroke?
With Right middle lobe of lung consolidation, 2° pneumonia?
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