52 /M , saree weaver by occupation presented with h/o slurring of speech ,deviation of mouth -that lasted for 1 day and resolved on same day . Brain imagining was done which showed cerebellar infarct and denovo HTN + patient was asked to continue medication regularly but he didn’t
He is chronic smoker 1 pack of beedi/day and chronic alcoholic since 30 years consumes 90 -180 of Ib thrice weekly
Pt gives h/o - giddiness -5 days back at 7 am in the morning pt was on routine works and suddenly at 7am .pt felt giddiness and took rest .it was associated with 1 episode of vomiting on the same day pt had h/o postural instability , while walking to and was about fall no seizure like activity
Pt was assyptomatic for 3 days then he consumed small amount of alcohol
Pt was assymptomatic till 3pm then the patient developed -giddiness , sudden onset and gradually progressive , continuous and increased on getting up from bed , while walking , associated with B/L hearing loss , aural fullness , tinnitus present
Postural instability - unable to walk without supports swaying present
Vomitings - 2-3 episodes /day , nonprojectile ,non bilious containing food particles
No diplopia , dysphagia , dysarthria , deviation of mouth , weakness of Limbs , bladde and bowel incontinence , no sensory symptoms
CNS
Hmf- intact
Motor system
Rt. Lt
Tone ul N N
Tone ll. N. N
Power ul. 5/5. 5/5
Ll. 5/5. 5/5
Reflexes +2 +2
Gait - wait based - ataxic gait
Cranial nerves -
8th - Rennes bc>ac. Ac> bc
Weber’s - no lateralisation
NYSTAGMUS- Bilateral horizontal nystagmus, vertical upbeat nystagmus, more on right lateral position with a fast component to the left.
INVESTIGATIONS:
COMPLETE URINE EXAM:
Colour- Pale yellow
Appearance- cloudy
Reaction- Acidic
Sp. Gravity- 1.010
Albumin- +
Sugar- nil
Bile salts- Nil
Bile pigments- Nil
Pus cells- 3-4
Epithelial cells- 2-3
Red blood cells- Nil
Crystals- Nil
Casts- Nil
Amorphous deposits- Absent
Others- Nil
RFT:
Urea- 28 mg/dl
Creatinine- 0.9 mg/dl
Uric acid- 7.4 mg/dl
Calcium- 9.8 mg/dl
Phosphorous- 1.3 mg/dl
Sodium- 140 mEq/L
Potassium- 3.5 mEq/L
LIVER FUNCTION TESTS:
Total Bilirubin- 2.00 mg/dl
Direct bilirubin- 0.55 mg/dl
SGOT (AST)- 17 IU/L
SGPT (ALT)- 18 IU/L
Alkaline phosphatase- 187 IU/L
Total proteins- 7.2 g/dl
Albumin- 4.5 g/dl
A/G Ratio- 1.72
CT SCAN- Computed tomography scan of the brain was done, which revealed a cerebellar infarct.
2D ECHO- Done on 19/05/21, shows good LV systolic function
No MS/AS
Diastolic Dysfunction present
PROVISIONAL DIAGNOSIS:
Cerebellar Ataxia secondary to Acute Cerebrovascular Accident (CVA) with infarct in the right inferior cerebellar hemisphere.
TREATMENT HISTORY:
Tab Veratin 8 mg PO TID
Inj Zofer 4 mg IV/TID
Tab Ecosprin 75 mg PO/OD
Tab Atorvostatin 40 mg PO/HS
BP monitoring- 4rth hourly
Tab Clopidogrel 75 mg PO/OD
Inj Thiamine 1 AMP in 100 ml NSPO/BD
Tab MVT PO/OD
ADVICE ON DISCHARGE-
Tab Vertin 8 mg PO TID - 1 week
Tab Zofer 4 mg IV/TID - 1 week
Tab Ecosporin 75 mg PO/OD - 1 week
Tab Atorvostatin 40 mg PO/HS - 1 week
Tab Clopidogrel 75 mg PO/OD - 1 week
Tab MVT PO/OD - 1 week
FOLLOW UP-
Review to OPD after 10 days
Popular posts from this blog
MEDICINE BLENDED BIMONTHLY ASSIGNMENT (MAY) I have been given the following cases to analyse and solve, in an attempt to understand the topic of 'Patient clinical data analysis' to develop my competency in reading and to comprehending clinical data including history, clinical findings, investigations and diagnosis, and then come up with a treatment plan. This is the link of the questions asked regarding the cases: http://medicinedepartment.blogspot.com/2021/05/online-blended-bimonthly-assignment.html?m=1 Below are my answers to the medicine assignment based on my comprehension of the cases, divided as per the system concerned: 1) PULMONOLGY CASE A https://soumyanadella128eloggm.blogspot.com/2021/05/a-55-year-old-female-with-shortness-of.html Q1. What is the evolution of the symptomatology in this patient in terms of an event timeline and where is the anatomical localization for the problem and what is the primary etiology of the patient's problem? ANS. Timeline-
Kausalya Varma, MBBS 8th semester Roll no: 59 This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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 diagnosis and treatment plan. A 49 year old male with Viral pneumonia secondary to COVID-19 Following is the view of my case (history as per date of admission): CASE- A 49 year old male patient was
INVESTIGATIONS:
COMPLETE URINE EXAM:
Colour- Pale yellow
Appearance- cloudy
Reaction- Acidic
Sp. Gravity- 1.010
Albumin- +
Sugar- nil
Bile salts- Nil
Bile pigments- Nil
Pus cells- 3-4
Epithelial cells- 2-3
Red blood cells- Nil
Crystals- Nil
Casts- Nil
Amorphous deposits- Absent
Others- Nil
RFT:
Urea- 28 mg/dl
Creatinine- 0.9 mg/dl
Uric acid- 7.4 mg/dl
Calcium- 9.8 mg/dl
Phosphorous- 1.3 mg/dl
Sodium- 140 mEq/L
Potassium- 3.5 mEq/L
LIVER FUNCTION TESTS:
Total Bilirubin- 2.00 mg/dl
Direct bilirubin- 0.55 mg/dl
SGOT (AST)- 17 IU/L
SGPT (ALT)- 18 IU/L
Alkaline phosphatase- 187 IU/L
Total proteins- 7.2 g/dl
Albumin- 4.5 g/dl
A/G Ratio- 1.72
CT SCAN- Computed tomography scan of the brain was done, which revealed a cerebellar infarct.
2D ECHO- Done on 19/05/21, shows good LV systolic function
No MS/AS
Diastolic Dysfunction present
PROVISIONAL DIAGNOSIS:
Cerebellar Ataxia secondary to Acute Cerebrovascular Accident (CVA) with infarct in the right inferior cerebellar hemisphere.
TREATMENT HISTORY:
Tab Veratin 8 mg PO TID
Inj Zofer 4 mg IV/TID
Tab Ecosprin 75 mg PO/OD
Tab Atorvostatin 40 mg PO/HS
BP monitoring- 4rth hourly
Tab Clopidogrel 75 mg PO/OD
Inj Thiamine 1 AMP in 100 ml NSPO/BD
Tab MVT PO/OD
ADVICE ON DISCHARGE-
Tab Vertin 8 mg PO TID - 1 week
Tab Zofer 4 mg IV/TID - 1 week
Tab Ecosporin 75 mg PO/OD - 1 week
Tab Atorvostatin 40 mg PO/HS - 1 week
Tab Clopidogrel 75 mg PO/OD - 1 week
Tab MVT PO/OD - 1 week
FOLLOW UP-
Review to OPD after 10 days
Comments