somaramreddy

Hello everyone I'm a medical intern.This blog is to share my experiences and cases I came across during this period

This is an online E log book to post and discuss our patient's de-identified health data posted after taking informed consent where we discuss patient-centered clinical problems through series of discussions among the community of experts without letting the patient move to distant places to different doctors with an aim to solve their clinical problems with the collective best evidence input from them. This online platform also reflects my patient-centered learning portfolio.

Case presentation:

A  66  year  old  male  patient came  to  the  hospital  with chief  complaints of

 1.Giddiness since  5days,  

Slurring  of  speech  since 5days and

 Difficulty  in  walking since  5days.

HOPI : 

Pt.was  apparently asymptomatic 6days  ago,then  he developed  giddiness which  was progressive  and  continuous in  nature  from  5  days  and is  associated with one  episode of vomiting  (contentfood particles,non bilious  and  non  bile stained). 

Following which  he  went to  the  RMP and his  BP  was 220mmhg,then he  went to Nalgonda hospital and  they did CT  scan  and  was referred  to  Kamineni  hospital.

Pt.also  had  complaints  of  slurring  of  speech  since  5days  and  is associated  with  deviation  of  mouth  towards  left  side  and  inability  to close  the  right  eye  fully. • • • • • 

Pt.is  not  able  to  squat  and  he  is  not  able  to  get  up    from  sitting position,  there  is  difficulty  in  walking  and  holding  chappal. 

No  H/o  paraesthesia,no  tingling  and  numbness Sensations  are  intact,

pt.able  to  appreciate  clothes  on  body.

Pt is  able  to  button  and  unbutton,able  to  mix  food  properly  and  can eat. 

No bowel  and  bladder  involvement.

Past  History: 

In  2011,pt.had  chest  pain  for  1week,went  to  some  hospital  and  was diagnosed  with  MI  for  which  PTCA  stenting  of  RCA was done.

 He  was  also  diagnosed  as  Hypertensive  during  the  same  time  and  is on  regular  antihypertensive  medication. 

He  is  not  a  k/c/o  DM,Asthma,  Epilepsy  and  Tuberculosis.

Personal  History:

He  is  farmer  by  occupation  and   smoker (Smokes 7-8 cigarettes per day)and  occassional alcoholic  from 40years. 

 Drug  history: 

No  similar  complaints  among  family  members.

Drug  history: On regular  antihypertensive  medication.

General  physical  examination: 

pt.is  conscious,  coherent,  cooperative.

 No signs  of  Pallor,Icterus,Cyanosis,  Clubbing,Lymphedenopathy  and generalised  edema. 

Vitals: 

TEMP-pt.is  afebrile 

PR:87bpm 

RR:21cpm

 BP:160/90mmhg.

Spo2:98% in room air

GRBS:108mg/dl

CNS examination:
 Higher mental functions- conscious,coherent,oriented to time,place and person .

 Memory-intact short term and long term
 Recall- intact
 Calculation: attention

Speech-Slurring of speech present and pt.is not able to pronounce pa,ba,ma clearly.

Gait-Broad based gait

Cranial nerves : intact

Motor system:                     Right.                   Left
         Bulk    :      UL  -----  Same on both sides              
                           LL  -----     Same on both sides                                   

          Tone :      UL  ---- Hypotonic on both sides                      
                           LL  ---- Hypotonic on both sides                            

       Power:

                            UL:         4/5.                       4/5

                            LL:.         4/5.                      4/5

     Reflexes:               Right.                      Left

     Biceps——.                 2+                       2+
     Triceps —-                  3+                      3+
     Supinator—-      Absent.                      Absent                                 
     Knee———-            3+.                         3+       

     Ankle--------.          2+                           2+                                                         

     Plantar   :.        Babinski positive,.     Normal                                        

SENSORY SYSTEM:

                         Rt                     Lt

  pain                N                      N 

Touch               N                      N

Temperature   N                      N 

Vibration -UL   N                      N

                 -LL    N.                    N

Stereognosis    N                    N

Graphesthesia - N.                  N

Tactile discrimination- N        N

Two ponit discrimination-✓      ✓

             

CEREBELLUM:

 Nystagmus  :(  present on left lateral gaze fast beating component to left side)       

        -

Scanning&speech   -Absent              

Hypotonia                  -   present                

Dysdiadochokinesia   -       VIDEO        

Finger nose test        -     

Heel sheen test         -      VIDEO     

Tandem walking--Not able to walk on a straight line.(VIDEO)

Rombergs test:Swaying present towards the right side.(VIDEO)

Respiratory System Examination:
No dyspnea, wheeze,
Breathsounds- vesicular
No added breath sounds

CVS examination:
 S1 and S2 heard
No added murmurs

Per abdomen examination:
 Abdomen: scaphoid,soft
 No tenderness, local rise of temperature,
 Hernial orifices : free
 Bowel sounds-sluggish

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