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 COMM
80 years male who is a farmer by occupation came to casuality with chief complaints of vomiting 2 episodes since morning and giddiness since morning.
HOPI:
- Patient was apparently asymptomatic 4 years back and on road in village health checkup he was diagnosed to have hypertension and he was put on tablet atenolol 50 mg since 4 years.
- Today morning, he woke up and ate food and after 2 1/2 hours, he went to his work in field, while working in the field he had sudden onset of giddiness followed by vomitings-2 episodes - bilious,non projectile type not associated with pain abdomen, fever, loose stools.
- Vomitings followed by giddiness (self reeling type) since morning - sudden onset aggravated with movements or sitting up, swaying while walking present, associated with headache holocranial type, associated with nausea and vomitings.
- No history of loss of consciousness, seizures, diplopia, blackouts, chest pain, constipation, sweating and palpitations, earache, aural fullness or discharge, tinnitus
- No complaints of weakness, tingling or numbness of limbs, difficulty in chewing, swallowing, deviation of mouth
- No bowel and bladder incontinence.
PAST HISTORY:
- K/C/O Hypertension since 4 years - on treatment TAB. ATENOLOL 50 mg
- Not a K/C/O diabetes mellitus/TB/Epilepsy/BA/CAD/CVA
PERSONAL HISTORY:
Diet- mixed
Sleep- adequate
Appetite- decreased since 10 days
Bowel and bladder movements- regular
No known allergies
- ALCOHOLIC SINCE 40 YEARS- 3 times/week 90 ml
- SMOKER SINCE 40 YEARS- 1 packet/day
FAMILY HISTORY: Not Significant
GENERAL EXAMINATION:
-Patient is Conscious, coherent and cooperative.
-No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy, edema.
VITALS:
Temperature - Afebrile
PR- 68 bpm
RR- 14 cpm
BP- 120/70 mmHg
SpO2- 99% at RA
GRBS- 132 mg/dL
SYSTEMIC EXAMINATION:
CVS- S1S2 heard, no murmurs
RS- BAE+, NVBS+
P/A- Soft, Non-tender
CNS:
Patient is oriented to time,place,person
Memory : recent, remote intact
Speech: Normal
Cranial nerves: Intact
Motor system:
Power-5/5 in both upper and lower limbs
Tone- Normal in bilateral upper and lower limbs
Sensory system: crude ,pain, temperature, fine touch, joint position, proprioception are normal in all dermatomes
GCS: 15/15
Reflexes :
Biceps, Triceps, Supinator, Knee and ankle reflexes were absent
Plantars: mute
Cerebellum:
Finger nose coordination +
Knee heel coordination +
No dysdidokinesia.
Nystagmus+ in both horizontal and vertical gaze.
INVESTIGATIONS:
Hemogram
Hemogram
CUE:
PT,APTT,INR:
ECG
ECG
USG ABDOMEN:
MRI BRAIN:
ASSESSMENT:
Giddiness under evaluation secondary to ?PCA Stroke with Hypertension.
ENT REFERRAL:
PLAN OF CARE:
1) INJ. THIAMINE 1 amp in 100 ml NS IV/TID
2) INJ. OPTINEURON 1 amp in 100 ml NS Slow IV/OD
3) INJ. PANTOP 40 mg IV/BD
4) INJ. ZOFER 4 mg IV/TID
5) TAB. PROMETHAZINE 25 mg PO/TID
SOAP NOTES
Day 2
SUBJECTIVE:
No episodes of vomitings
Giddiness reduced than yesterday,but still present
Head ache and nausea
OBJECTIVE:
Bp:120/70mmhg
PR 83bpm
RR: 16
Spo2 :98% at room air
Cvs:s1s2+
Rs: NVBS
Nystagmus +
ASSESSMENT:
PCA stroke with hypertension
Giddiness under evaluation
PLAN OF CARE:
ENT Opinion to be taken
1) INJ. THIAMINE 1 amp in 100 ml NS IV/TID
2) INJ. OPTINEURON 1 amp in 100 ml NS Slow IV/OD
3) INJ. PANTOP 40 mg IV/BD
4) INJ. ZOFER 4 mg IV/TID
5) TAB. PROMETHAZINE 25 mg PO/TID
Day 3
SUBJECTIVE:
No episodes of vomitings
Giddiness reduced than yesterday, but still present
Head ache and nausea +
OBJECTIVE:
Bp:150/90mmhg
PR 83bpm
RR: 16
Spo2 :98% at room air
Cvs:s1s2+
Rs: NVBS
Nystagmus +
ASSESSMENT:
Giddiness under evaluation with PCA Stroke
PLAN OF CARE:
1) INJ. THIAMINE 1 amp in 100 ml NS IV/TID
2) INJ. OPTINEURON 1 amp in 100 ml NS Slow IV/OD
3) INJ. PANTOP 40 mg IV/BD
4) INJ. ZOFER 4 mg IV/TID
5) TAB. PROMETHAZINE 25 mg PO/TID
Day 4
ICU Bed-2 case shifted to Ward:
S: Headache + , giddiness +
No nausea, No episodes of vomitings
O:
Pt. is C/C/C
Afebrile
Bp: 120/70 mmHg
PR: 80 bpm
RR: 14 cpm
GRBS-: 109 mg/dL
Spo2 :98% at room air
CVS: S1S2 +
RS: BAE+ , NVBS+
P/A: Soft, Non-tender
Nystagmus +
B/L Plantars: Flexion
A :
PCA Stroke with Hypertension with Alcohol and Tobacco Dependence Syndrome (Chronic Smoker and alcoholic )
P :
1) TAB. PROMETHAZINE 25 mg PO/TID
2) INJ. VERTIN 16mg PO/TID
3) TAB. AMLONG 5 mg PO/OD (8 am)
4) TAB. PANTOP 40 mg PO/OD
5) TAB. AUGMENTIN 625 mg PO/BD
6) TAB. THIAMINE 100 mg PO/BD
7) TAB. NAPROXEN 250 mg PO/BD
8) Vitals monitoring - 4th hrly
10) GRBS 12th hrly
