A 38 year old male with c/o of unable to stand on his own,unable to eat on his own,urinary incontinence

 38 year old male with c/o unable to stand on his own,unable to eat on his own and urinary incontinence 

march 3,2023

M.sandhya 

roll no 94


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-centered online learning portfolio and your valuable inputs on the comment box

38 year old male who works in a mobile network company  by occupation and came to opd with

CHIEF COMPLAINTS;
 unable to stand on his own and unable to eat on his own since 20 days
urinary incontinence since 15 days

 
HISTORY OF PRESENT ILLNESS;
Patient was apparently asymptomatic 20 days back then 
he  suddenly developed inability to stand on his own and also inability to eat on his own,gradually progressive 
initially patient used to do his own activities but gradually stopped doing his work and got bed ridden
c/o urinary incontinence since 15 days before that patient informed about his urination but since 15 days he is passing urine involuntary
attenders also complain of patients self talking
(hallucinations -visual)
no h/o fever,SOB,chest pain,pain abdomen
slurring of speech since 15 to 20 days,last alcohol binge 20 days back
h/o similar complaints in the past in Nov 2022,he was taken to a local hospital with c/o weakness of lower limbs subsided on treatment 
h/o admission in dac,in our hospital 6 to 7 years back,stayed for 2 months and started consuming alcohol again 15 days after discharge 

PAST HISTORY;

N/k/c/o DM,HTN,TB,EPILEPSY, CVA,CAD,THYROID DISORDERS 

FAMILY HISTORY:-
insignificant 
PERSONAL HISTORY:-

DIET-mixed
APEPTITE- Lost since 15 days
BOWEL &BLADDER-Regular
SLEEP-Adequate.
ADDICTIONS- Alcohol regular 300 ml/day since 12 to 13 years

GENERAL EXAMINATION:-
Patient is drowsy, coherent,cooperative.
Well oriented to time place & person 
Moderate built and moderately nourished.
Pallor absent
No cyanosis, clubbing, icterus, LN
Vitals : 
Bp -130/70 mmhg
PR -86 bpm ;
RR : 18cpm
Spo2 : 99 on RA
GRBS:106 mg/dl
CNS examination:
SYSTEMIC EXAMINATION :
CNS EXAMINATION;

CNS:                 R                L
Tone-  UL         N                N
            LL    hypertoina hypertonia         
 Power-UL        5/5            5/5
             LL        5/5            5/5
 Reflexes- Biceps- +        +
                 Triceps- +       +
                 Supinator- +    +
                 Knee-    +       +
                 Ankle-  +          +
                 Plantar- flexion   flexion
Sensory examination: Normal
Rhomberg's negative
Cerebellum:
Nystagmus-absent
Tremors- absent
Finger nose test- normal
Dysdiadokinesia- absent

CARDIOVASCULAR SYSTEM:-
S1 S2 heard 
No murmurs.
RESPIRATORY SYSTEM:-
Dyspnea-absent
No wheeze
Breath sounds - vesicular
No Adventitious sounds 
ABDOMINAL EXAMINATION:-
No tenderness 
No palpable liver and spleen.
Bowel sounds - present.




INVESTIGATIONS:-

psychiatry referral taken i/v/o alcohol consumption. Advised
Tab.lorazepam 20 mg PO/OD
Inj.thiamine as per guided by physician



MRI      
             












03/03/2023

2D-ECHO



CHEST X-RAY


ECG


USG ABDOMEN;;


      

TREATMENT;
1. inj.thiamine 500 mg in 100 ml NS I.V /TID
2.Inj.optineuron 1 amp in 100 ml NS I.V/OD
3.I.V fluids 1 NS,1 RL @100 Ml/hour
4.GRBS monitoring 4th hourly










Comments

Post a Comment

Popular posts from this blog

General medicine case discussion

Online blended bimonthly assignment toward summative assessment for the month of May 2021 M.SANDHYA ROLL NO: 89 8th sem Pulmonology (10 Marks)  A) Link to patient details: https:// soumyanadella128eloggm. blogspot.com/2021/05/a-55- year-old-female-with- shortness-of.html Questions: 1) 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? 2) What are mechanism of action, indication and efficacy over placebo of each of the pharmacological and non pharmacological interventions used for this patient? 3) What could be the causes for her current acute exacerbation? 4. Could the ATT have affected her symptoms? If so how? 5.What could be the causes for her electrolyte imbalance? 1Q) what is the evolution of the symptomatology in this patient interms of an event timeline and where is the anatomical localisation for the problem and what is th
Read more

80 year old female with SHORTNESS OF BREATH AND COUGH

Image
80 year old female with SHORTNESS OF BREATH AND COUGH June 6, 2022 M.sandhya 1701006117 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-centered online learning portfolio and your valuable inputs on the comment box 80 year old female who is dailywaged labour by occupation and came to opd with CHIEF COMPLAINTS;   shortness of breath since 10 days  dry cough since 3 days HISTORY OF PRESENT ILLNESS; Patient was apparently asymptomatic 20 yrs back then  she had history of giddiness and headache  for which she went to hospital and diagnosed with hypertension and from then on regular medication Currently using Tab
Read more