GENERAL MEDICINE SHORT CASE

 


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MEDICINE CASE DISCUSSION:

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.



Hallticket number:1701006061



CHIEF COMPLAINTS :


weakness of lower limbs since 4days


VIEW OF THE CASE :


He had a history of fall 1 year ago and 4 months back when he developed pain in the right hip region, which was insidious in onset and intermittent at the beginning. Aggrevated on movement and relieved on rest and medication. 

      He went to the hospital 2 months ago when the pain progressed and became continuous, and was diagnosed with avascular necrosis of the femur due to a trauma to the hip one year ago and given medications

    medications:

                   Tab.Gabapentin&Nortryptyline

                     Tab.pantoprazole&Domeperidone

                       Tab.ETORICOXIN 
                       THIOCOLCHICOSIDE (4mg)
                    Tab.METHYL COBALAMIN,Biotin
                    TAB.FERROUS ASCORBATE,
                   FOLIC ACID And   ZINC TABLETS.


4 days ago, patient developed weakness in the lower limb which progressed upto the hip.


He was taken to the hospital and was prescribed medications. On starting the medication, the weakness worsened. 


The next morning, patient required assistance to walk and sit up but was able to feed himself. The weakness progressed so that by the evening he was unable to feed himself. He only responded if called to repeatedly. 


The weakness was not associated with loss of consciousness, slurring of speech, drooping of mouth, seizures, tongue bite or frothing of mouth, difficulty in swallowing.


No complaints of any headache, vomitings, chest pain, palpitations and syncopal attacks. 


No shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, abdominal pain or burning micturition. 




Past History:


No similar episodes in the past. 


Patient is a known case of diabetes since 12 years. He is on insulin therapy 



No history of hypertension, tuberculosis, epilepsy, asthma, thyroid and CAD. 


No surgical history. 


Personal History:

Diet: Mixed 

Appetite: Normal

Sleep: Adequate 

Bowel and Bladder: Regular

No allergies

Addictions;

alcohol intake from 25 years 90ml per day


Started smoking from 10 years  



Family History:


No similar history in family. 



GENERAL EXAMINATION:


Patient is examined in a well lit room after taking informed consent. 

Patient is conscious, coherent and cooperative. 

He is moderately built and moderately nourished. 



Pallor: Present 

Icterus: absent

Cyanosis: absent

Clubbing: absent 

No generalized Lymphadenopathy

Edema: present




Vitals: 

Blood Pressure: 124/72 mmHg

Respiratory Rate: 17 cycles per minute

Pulse: 70 bpm

Temperature: Afebrile



Central Nervous System: 


Higher mental functions

          • conscious

          • oriented to person and place

          • memory - able to recognize their family members and recall recent events

          • Speech - no deficit

  

  4b) Cranial nerve examination:


I- Olfactory nerve- sense of smell present

II- Optic nerve- direct and indirect light reflex present

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis

V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.

VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.

VIII- Vestibulocochlear nerve- no hearing loss


IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised


XI- Accessory nerve- sternocleidomastoid contraction present


XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue



Motor system :


Attitude - right lower limb flexed at knee joint


Reflexes:

                          Right Left 


Biceps              2+             2+


Triceps             2+             2+ 


Supinator          2+           2+


Knee                     2+         2+ 


Ankle                     2+        2+ 

Superficial reflexes and deep reflexes are present , normal




Muscles power:   

      muscle power reduced in upperlimbs and lowerlimbs muscles                            



                                  Right        Left

BULK 

Arm

Forearm                  19cm      19cm

Thigh                        42cm.     42cm

Leg                            28cm.     28cm                         



TONE

 Upper limbs            N                      N


 Lower limbs          N                         N



Gait is normal

No involuntary movements


Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal


Attitude - right lower limb flexed at knee joint


Tone - Normal on right side



            Normal tone on left side

Bulk - Rt Lt. 

Arm: cm cm

Forearm 19cm 19cm


Thigh 42 cm 42cm


Leg 28cm 28cm


Cardiovascular System:

S1 S2 heard, no murmurs


Respiratory System: 


Bilateral air entry present

normal vesicular breath sounds,no added sounds


Gastrointestinal System: 

Soft, non-tender, no organomegaly



ECG :


on 02/06/22

          



   

on 02/06/22

electrolytes:

Potassium:2.5meq/L

Chloride:110meq/L

Sodium : 145 meq/L




On 05/06/22

sodium:142
Potassium:3.9
Chloride:103



Blood sugar: 195 mg/dl (on 02-06-22)





Diagnosis: weakness due to metabolic cause like hypokalemia



TREATMENT


on day 1


1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) 2 amp KCL in 500ml NS slowly over 4-5 hrs




On day 2


1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) proteolytic enema

8) syrup cremaffine


9) tab spironolactone




On day 3


1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) proteolytic enema

8) syrup cremaffine plus 15ml/po/od

9) tab spironolactone 25mg/po/od

10) tab azithromycin 500mg OD

11) high protein diet 




On day 4

1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

5) normal oral diet

6) inj HAI - TID

7) tab ultracet QID

8) syrup cremaffine plus 15ml/po/od

9) tab spironolactone 25mg/po/od

10) tab azithromycin 500mg OD

11) high protein diet 



On day 5

1) tab ecospirin 70mg OD

2) tab atorvas 10mg OD

3) inj NS, RL at 70ml/hr

4) syrup potchlor 15ml/po/tid

                               


5) normal oral diet

6) inj HAI - TID

7) tab ultracet 1/2 po/ QID

8) syrup cremaffine plus 15ml/po/od

9) tab spironolactone 25mg

10) tab azithromycin 500mg OD


11) high protein diet















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