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 .
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
Bulk : UL ----- Same on both sides
LL ----- Same on both sides
Tone : UL ---- Hypotonic on both sides
LL ---- 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+
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
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