Sridevi e-log

This is an online E-log book to discuss our patient’s de-identified health data shared after taking his/her/guardian 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 these patient’s clinical problems with collective current best evidence based inputs.

This e-log also reflects my patient-centered online learning protfolio and your valuable inputs on comment box is welcomed.Hey 

Here is the case i have seen:

A 60yr old male came to the hospital on with the chief complain of head ache and neck pain since 10 days,tingling sensation of both foot since 1 day,slippage of footwear and burning micturation since 1day 

History of present illness:

Pt was apparently asymptotic 10 days back ,then developed fever for one day associated with body pains for which he went to RMP,took medication (unknown) in the afternoon.There is an episode of giddiness in evening and sustained trauma while walking due to slippage.

No h/o loc,ent bleed,blurring of vision,vomiting ,seizures following trauma but complaining of headache since then.

No h/o weakness of upper and lower limbs,no h/o difficulty in getting up from squatting position,combing hair,buttoning and unbuttoning,wearing chappal

Complaining of slippage of footware while walking since morning

Assosciated with cotton wool sensation and tingling sensation in bilateral foot

No h/o vomiting,loose stools,pain abdomen,increase or decrease in urine output ,cough,sob,chest pain,palpitations 

Past history :

K/c/o hypertension since 5 yrs on T.telma -AM(40/5) OD

Diabetes since 5 years on T.glimi-MI OD

Not a k/c/o asthma , jaundice,epilepsy

Personal history :

Alcoholic since 40 yrs,4-5times per month,90ml

Drug history:

 T. Telma-AM since 5 yrs

  T. glimi-MI since 5 yrs

General Examination:

 Pt is conscious,coherent,cooperative 

     moderately built ,moderately nourished

Vitals - Temp-Afebrile

               BP-120/70mmhg

               PR-82bpm

               RR-18cpm

               Grbs-245mg/dl

CNS examination:

Higher mental functions: pt is conscious ,speech is normal

Motor system:

Bulk:           Rt     Lt

         UL-   N       N

          LL-   N.      N

Tone: 

         UL-   N.       N

         LL-    N        N

Power:

         UL-  5/5       5/5

         LL-   5/5       5/5

Reflexes:

 Triceps reflex- 2+

 Biceps reflex-1+

 Supinator reflex-2+

 Knee reflex-absent on both sides

 Ankle reflex-absent on both sides

  Plantar reflex-extended

Sensory system:intact

Cranial nerves:intact

No cerebellar signs

No signs of meningeal irritation 

Respiratory system:

Shape of chest is normal, trachea is central in position,b/l air entry is present,no added sounds

CVS:

S1 S2 heard , no murmurs ,jvp is normal,no parasternal heave ,palapble trills 

Per abdomen:

Shape of abdomen-distended 

                              Waist circumference-116cms

No local rise of temperature and no tenderness,no palpable mass ,no visible peristalsis,hernial orifices are free, no organomegaly,bowel sounds heard

Hb-11.8g/dl

Rbs-84mg/dl

Cue- albumin +

          sugar ++ 

          pus cells=4-5

          epithelial cells=2-3

Serum creatinine -0.9

Serum electrolytes- Na-137mEq/l

                                    K-4.3mEq/l

                                    Cl-95mEq/l

Diagnosis:

Chronic RMCA infarct

Transient ischemic attack

Uncontrolled diabetes mellitus

K/c/o HTN

Treatment:

Tab.ecospirin -AV 75/20mg PO OD

Tab.clopidogrel 75mg OD

Tab.pregabalin 75mg OD H/S

Tab.telma 40mg OD

Tab.pcm 650mg PO OD

Inj.human actrapid insulin s/c 

      Acc to sliding scale

  8am—2pm—8pm

Grbs charting 6th hrly

Moniter vitals

I/o charting

Discussion:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4146153/

The American Heart Association has revised the proposed definition of TIA to a tissue-based term without time limit, previously 1 hour. The recent definition of a TIA includes “any neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction” (Easton et al., 2009), of typical symptom duration of less than 1 to 2 hours. According to this definition, a prolonged TIA might occur. Diagnostic correctness depends on the extent of the evaluation.