A 62 year old Male, c/o 4-5 episodes of involuntary movements of both upper limbs and lower limbs
S.Shivakumar Sriram 152
A 62 year old Male, c/o 4-5 episodes of involuntary movements of both upper limbs and lower limbs since morning on 20/10/2022.
October 21, 2022
Chief complaints: Pt c/o involuntary movements since morning 6-7 episodes since morning .
c/o uprolling of eyes.
HOPI: Pt was apparently asymptomatic till morning. Then he had an episode of involuntary movements of both UL and LL at 6:30AM on 20/10/2022,which lasts for 4-5 minutes with up rolling of eyes. Not ass with vomiting, involuntary micturition, defecation and no post ictal confusion.
No froathing,no tongue bite during the episode.
He had 5-6 similar episodes till afternoon .
No developmental delay.
PAST HISTORY:
K/c/o HTN since 4-5 years
Not a k/c/o DM, HTN, ASTHMA, CAD.
No history of similar complaints in the past.
H/o surgery 4months back for? Intestinal ulcer and he stayed in hospital for 20 days.
PERSONAL HISTORY:
Diet- mixed
Appetite-normal
Bowel and bladder movements- regular.
Addictions- He used to consume 90ml of whisky per day for the past 40 years. But he stopped consuming it 4 months back.
Allergies- none
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative. Well oriented to time, place and person.
Moderately built and moderately nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
VITALS:
Temp- 98°F
BP-130/90MMHG
RR-18CPM
PR- 68BPM.
GRBS-549mg/dl on the day of admission.
Spo2 - 100%
SYSTEMIC EXAMINATION:
CVS: S1,S2 Heard
No Murmurs
RS: B/L Normal Vesicular Breath Sounds Heard.
P/A: soft, non tender.
CNS EXAMINATION:
Higher functions:
Right handed
Conscious
Oriented to time ,place and person
Memory: recent- present
Immediate: present
Remote: present
SPEECH:
Normal
No delusions or hallucinations
Cranial nerve examination:
I- Olfactory nerve- sense of smell present
II- Optic nerve- direct and indirect light reflex present
III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis
V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.
VII- Facial nerve- face is symmetrical, able to do forehead wrinkling
VIII- Vestibulocochlear nerve- no hearing loss
IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised
XI- Accessory nerve- sternocleidomastoid contraction present
XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue
SPINOMOTOR:
Right Left
Bulk: U/L
arm : normal Normal
Forearm: normal Normal
L/L:
thigh: normal Normal
Leg: normal Normal
Tone: U/L: Normal Normal
L/L: Normal Normal
POWER:
U/L
Hand : 4/5 4/5
Elbow: 4/5 4/5
Shoulder : 4/5 4/5
L/L
Ankle: 4/5 4/5
Knee: 4/5 4/5
Hip: 4/5 4/5
Reflexes:
Biceps: - -
Triceps: + +
Supinator: + +
Knee: + +
Ankle: + +
Plantar: Flexion Flexion
Sensory system :
crude touch : Present present fine touch : Present present pain : Present present
vibration : Present present temperature : Present present stereognosis: Present present 2 point discrimination: present present
graphaesthesia: Present present
Coordination; present
GAIT :NORMAL
Investigations:
HBA1C:
LFT:
Serology: Negative for HIV, HBS Ag, Anti HCV antibodies.
Investigations:
HBA1C:
LFT:
DIAGNOSIS:
FOCAL SEIZURES WITH DYSCOGNITION, DENOVO DM2 WITH UNCONTROLLED SUGARS.
Treatment:
1.INJ LEVEPILL 500 mG / IV /BD
2.INJ. LORAZ 2CC / IU /S0S
3.INJ • OPTINEURON 1 AMP IN 100 ML NS /IV/OD
4.INJ. HAI SC / TID / A/c to GRBS inform
INJ. NPH SC/BD
5) INJ. PAN 40 mg IV / OD/ BBF.
6) GRBS MONITORING.
7) 3-4 EGG WHITES/DAY.
8) MONITOR VITALS
9) INFORM SOS.
Popular posts from this blog
A 55yr old female complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days.
October 27, 2022
Image
CHIEF COMPLAINTS: Pt complains of fever,decreased appetite since 1 month, Breathlessness since 1 week,vomitings and loose stools since 3 days . HOPI: Patient was apparently asymptomatic 3 months back. Then she had multiple swellings in front of the left ear, for which she developed fever which was lowgrade, intermittent, no evening rise of temp, ass with decreased appetite since 1 month. She then had vomitings which was non bilious and non projectile, containing food particles. She had history of loose stools since 3 days, which is 4-5 episodes per day, watery in consistency. Past history: K/c/o Hypertension since 7 years. 7 yrs back she had c/o giddiness for which she went to hospital and was found to have HTN. Personal history: Diet- mixed Appetite-decreased Bowel and Bladder movements- regular. Addictions- Allergies- none General examination : Patient is conscious, coherent and cooperative. Well oriented to time, place and person. Moderately built and moderately nourished. No p
READ MORE
A 45 yr old male c/o fever since 5 days.Abdominal pain , loose stools and vomitings since yesterday.
October 15, 2022
Image
CHIEF COMPLAINTS : A 45 yr old male c/o fever since 5 days, abdominal pain , loose stools and vomitings since yesterday. HOPI : patient was apparently asymptomatic 5 days ago and then developed fever, which is low grade, not associated with chills and rigors and relieved on medication. He complains of diffuse pain abdomen since 11th October morning. He had 3-4 episodes of vomiting on the same day evening, food particles as content and non- bilious in nature .He had loose stools since evening the same day, which is of 5 -6 episodes and so he went to local hospital. He developed weakness of both upper and lower limbs and found to be having low potassium, correction was done and the weakness got improved. He now came with c/o abdominal pain , vomiting and loose stools. PAST HISTORY Not a k/c/o DM, Hypertension, Asthma, epilepsy, CAD, CKD. He went for a General checkup 6yrs ago, where he was diagnosed as HIV posi tive. He was on ART . He met with an accident 3yrs ago and got Righ
READ MORE
55 yrs old male patient with came with cheif complaints of abdominal pain since 5 days and chest pain since 2 days.
January 10, 2022
Image
Student- SHIVA KUMAR SRIRAM -2018. This is an 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 evidence based input This E blog also reflects my patient-centered online learning portfolio and your valuable inputs on the 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. CHEIF COMPLAINTS: Patient came with cheif complaints of abdominal pain since 5 days and chest pain since 3 days. HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic
READ MORE
Powered by Blogger
Report Abuse
Comments
Post a Comment