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.
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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 a diagnosis and treatment plan.
CASE:
A 63 year old female, shopkeeper by occupation, admitted in the ICU, originally came to Ophthalmology OPD with chief complaint of DOV since 6 months.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6 months ago when she developed DOV in her left eye, which was insidious in onset and gradual in progression.
She underwent cataract surgery on 27th October, 21 for immature senile cataract in her left eye, She was admitted in the post op ward after the cataract surgery.
She fell from the bed in her sleep at around 4:00 am in the morning on 31/10/21. Her daughter who was accompanying her noticed that she was irritable, and was unable to lift her right arm (there was restriction of movement and she wasn’t able to do overhead abduction)and both the lower limbs and that her mouth was also deviated to left side. She began to talk irrelevantly since then.
Not associated with giddiness
No h/o trauma to head
There was history of trauma to right shoulder thrice in the past few years.
PAST HISTORY
Patient is a known case of Hypertension since 10 years for which she has been taking Telvas 12.5 mg OD
She's also a known case of Diabetes since 5 years for which she's been on Glyciphage SR 500 mg OD
Not a known case of TB, Bronchial Asthma, epilepsy, COPD, Coronary Artery Disease.
PERSONAL HISTORY
Her appetite has decreased.
She takes mixed diet.
Bowel and Bladder movements are regular.
Sleep is disturbed.
No known addictions or allergies.
MENSTRUAL HISTORY
Attained menopause.
FAMILY HISTORY
Insignificant
TREATMENT HISTORY
Cataract surgery in right eye, 4 years ago.
PHYSICAL EXAMINATION
General Examination:
Patient was examined in a well lit room after taking consent.
She was conscious, cooperative, but irritable and insisted on going home and non-coherent.
She was moderately built and moderately nourished.
No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
VITALS:
She was afebrile.
Pulse rate - 84 bpm
Respiratory rate - 13 cycles per minute
Blood pressure - 120/80 mm of Hg
SpO2 - 92%
SYSTEMIC EXAMINATION
CVS : S1 S2 heard. No murmurs
RESPIRATORY SYSTEM : BAE +, No adventitious sounds present
PER ABDOMEN: Soft, Non tender, No organomegaly
CNS::
1) HMF - INTACT
2)MOTOR SYSTEM :
Right Left
Bulk:
Inspection. N. N
Palpation. N. N
Tone:
UL. N. N
LL. N. N
On 31/10/21
Upper Limb:
Shoulder:
Flexion. 3/5. 3/5
Extension. 5/5. 5/5
Abduction: 3/5. 3/5
Adduction: 5/5. 5/5
Elbow:
Flexion (biceps) 5/5. 5/5
Extension (triceps) 5/5. 5/5
Lower Limb:
Ilio psoas. 5/5. 5/5
Gluteus max. 5/5 5/5
Adductor femoris. 5/5 5/5
Hamstrings. 5/5 5/5
Quadriceps. 5/5 5/5
Tibialis ant. 5/5 5/5
Tibialis post. 5/5. 5/5
Ex. Digitorum L. 5/5. 5/5
Fl. Digitorum L. 5/5. 5/5
Ex. Hallucis L. 5/5. 5/5
Deep tendon reflexes:
Biceps: +2 +2
Triceps: +2 +2
Supinator: +2 +2
Knee: +2 +2
Ankle: +2 +2
Plantar: flexor flexor
Sensory:
STT:
Crude touch. + +
Pain. + +
Temp. + +
Post. Dorsal
Fine touch. present
Vibration. + +
Position. + +
CRANIAL NERVES : Intact
Cerebellar signs : Normal
On 1/11/21
On 2/11/21
INVESTIGATIONS
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