70M with Seizures,CVA and uncontrolled sugars,tracheostomised
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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan
CASE HISTORY:-
Chief complaints:-
H/o involuntary movements of left upper and lower limbs followed by unconsciousness 15 days ago.
Pt was born and brought up in nerada.He lead a healthy childhood living along with his family doing agriculture.He was illiterate,started farming at around 15 years of age and at 17 yrs of age started smoking due to peer pressure.At 25 years of age he got married to his wife and had 3 children .He had no health issues.20 years ago his middle child met with a Road traffic accident after that incident to allievate emotional distrubance he started consuming alcohol since then he consumes around 90 to 180ml of alcohol twice or thrice a week.He remained asymptomatic until 3 years ago then he had h/o generalised weakness and fever for which he went to hospital and diagnosed to have diabetes aa nd started on medication but due to financial reasons he used them irregularly and 1 and 1/2 yr ago one day he had weakness of right upper and lower limbs for which he was taken to nearby hospital there they diagnosed him of having CVA(right hemiparesis).He used medication and within 2 months his condition got improved and began to walk and do his daily activities.He discontinued medication after that.
15 days ago on his visit to in laws home he binged on alcohol for 3 days in sequence,decreased food intake and had an episode of involuntary movements of left upper and lower limbs followed by unconsciousness.They took him to hospital where he was found to have hypoglycemia.2 days later he got intubated i/v/o ?status epilepticus and later tracheostomised 3 days ago.
They brought the patient to casuality tracheostomised
Past history in brief:-KNOWN CASE OF CVA SINCE 1 and 1/2YEAR, USING MEDICATION.
KNOWN CASE OF TYPE 2 DM SINCE 3 YEARS, ON IRREGULAR MEDICATION
NOT A K/C/O HTN, CAD, BRONCHIAL ASTHMA, THYROID DISORDER, TB, EPILEPSY
Personal history:-
MIXED DIET
APETTITE NORMAL
REGULAR BOWEL AND BLADDER
KNOWN ALCOHOLIC SINCE 20 YEAR
KNOWN SMOKER SINCE 15 YRS OF AGE
NO SLEEP DISTURBANCES.
Vitals:-
PR:-98bpm
Bp:-130/80mm hg
Rr:-24cpm
Spo2:-98%
Fio2- 30,%
General examination:-PATIENTS IS ON MECHANICAL VENTILATOR.
MODERATLY BUILT AND NOURISHED
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPTHY,
EDEMA OF RIGHT UPPER LIMB SINCE 4 DAYS
Rs:-BLAE,Crepts+ in rt MA,LMA
Cvs:-S1S2 +,No murmurs
CNS:-
Pt is on drowsy but arousablestate
GCS:-E4VTM5
Tone rt lt
UL ↓. ↑
LL ↓. ↑
Power couldnt be elicited
Reflexes
B. T. S. K. A. P
Rt. 2+. - - - - flexion
Lt. 2+. 2+. - +. - flexion
Pupils- b/l normal size and normal light reflex
Corneal and conjunctival reflex-present b/l
Doll's eye reflex absent
No neck stiffness
Jaw jerk absent
Per abdomen:-soft,NT
Grbs:-133mg/dl
Investigations:-
Hemogram
Rft
Abg
Et tube c/s
blood c/s
tracheostomy c/s
Serial hemogram reports
serial RFT
LFt
ABG
CUE
FINAL DIAGNOSIS