A case of 60 year old Male
Name: J. Akash
21/01/2023
Roll no. 53
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.
Following is the view of my case :
A 60year old male farmer by occupation came to casuality with
C/O
Loss of speech since yesterday afternoon
apparently asymptomatic 30years ago then he had bilateral knee pain for which used pain killers
one month ago patient had fever not associated with nausea , vomitings,chills , headache,loose stools , giddiness went to local hospital in miryalaguda and necessary investigations were done and diagnosed with pulmonary kochs came to our hospital for further investigations and management .
ATT was started and discharged
patient came to pulmonology opd for follow up 2days ago ,ATT stopped due to derranged RFT and LFT
since last evening he had loss of speech . No deviation of mouth, No H/O epilepsy
No H/O nausea, vomitings, headache
No H/O SOB ,chest pain, palpitations , sweatings
No H/O loose stools , burning micturition
K/C/O CBNAAT positive -pulmonory kochs ,started on ATT &stopped
K/C/O CKD
regular alcoholic 90ml/day since 35years,smoker 1cigar/2days
INSIGNIFICANT FAMILY HISTORY
GENERAL EXAMINATION:
pt conscious, coherent, co-operative
No signs of pallor, icterus, clubbing, cyanosis,edema, lymphadenopathy
Bp-100/60mmhg
PR-72bpm
Temp-98°F
GRBS-92 mg/dl
CVS - S1,S2 heard , no thrills & Murmurs
RS - BAE + , NVBS
PA - Soft,Non tender,liver spleen not palpable
CNS-Patient is conscious
speech absent
RT LT
Tone : UL N N
LL N N
MSE : not elicitable
Reflexs :
B T S K A P
Absent reflexes flexion
INVESTIGATIONS:
21/01/2023
CT BRAIN:
CULTURES:
Blood culture: negative
Urine culture: >25/HPF pus cells seen ,E coli isolated
PROVISIONAL DIAGNOSIS:
?septic encephalopathy
secondary to urosepsis
k/c/o pulmonary kochs with ATT induced hepatitis
TREATMENT GIVEN:
IVF NS @30ml/hr
inj.ceftriaxone 2g iv/BD
Tab.ursodeoxycholic acid 300mg RT/BD
Tab.ecosprin AV 75/10mg RT/OD
Tab.Vitamin B1 10mg
Vitamin B2 10mg
vitamin B3 45mg
vitamin B5 50mg
vitamin B6- 3mg
B12- 1500 mcg
Tab.PCM 650mg RT/Sos
monitor vitals
21/01/2023
IVF NS @30ml/hr
inj.ceftriaxone 2g iv/BD
Tab.ursodeoxycholic acid 300mg RT/BD
Tab.ecosprin AV 75/10mg RT/OD
Tab.PCM 650mg RT/Sos
Tab.Neurobion forte PO/OD
monitor vitals
22/01/2023
UNIT 5
DR HIMAJA, PGY1
DR PAVANI, PGY2
DR SAICHARAN, PGY3
DR ABHINAYA, SR
DR AKASH, INTERN
DR HYNDAVI, INTERN
AMC DAY 2
AGE : 60 GENDER :M
S:
stools not passed
no fever spikes
no headache
O:
pt conscious, coherent, co-operative
Bp-110/60mmhg
PR-76bpm
Temp-98°F
CVS - S1,S2 heard , no added sounds
RS - BAE + , NVBS
PA - Soft,Non tender
CNS- speech absent
RT LT
Tone : UL N N
LL N N
MSE : not elicitable
Reflexs :
B T S K A P
Absent reflexes flexion
A:
? septic encephalopathy
TB/pyogenic meningitis
k/c/o pulmonary kochs with ATT induced hepatitis
P:
IVF NS @30ml/hr
D2 inj.ceftriaxone 2g iv/BD
Tab.ursodeoxycholic acid 300mg RT/BD
Tab.ecosprin AV 75/10mg RT/OD
Inj.Optineuron IV/OD
Tab.PCM 650mg RT/Sos
monitor vitals
23/01/2023
UNIT 5
DR HIMAJA, PGY1
DR PAVANI, PGY2
DR SAICHARAN, PGY3
DR ABHINAYA, SR
DR AKASH, INTERN
DR HYNDAVI, INTERN
AMC DAY 3
AGE : 60 GENDER :M
S:
stools not passed
no fever spikes
no headache
O:
pt conscious, coherent, co-operative
Bp-110/70mmhg
PR-76bpm
RR-16cpm
Temp-98°F
GRBS-105mg/dl
CVS - S1,S2 heard , no murmurs
RS - BAE + , NVBS
PA - Soft,Non tender
CNS- Pupils -B/L NSRL
RT LT
Tone : UL N N
LL N N
Power UL 4/5 4/5
LL 3/5 3/5
A:
? septic encephalopathy
To R/o pyogenic meningitis
k/c/o pulmonary kochs with ATT induced hepatitis
P:
IVF NS @30ml/hr
D2 inj.ceftriaxone 2g iv/BD
Tab.ursodeoxycholic acid 300mg RT/BD
Tab.ecosprin AV 75/10mg RT/OD
Inj.Optineuron IV/OD
Tab.PCM 650mg RT/Sos
monitor vitals
24/01/2023
UNIT 5
DR HIMAJA, PGY1
DR PAVANI, PGY2
DR SAICHARAN, PGY3
DR ABHINAYA, SR
DR AKASH, INTERN
DR HYNDAVI, INTERN
AMC DAY 4
AGE : 60 GENDER :M
S:
stools not passed
no fever spikes
no headache
O:
pt conscious, coherent, co-operative
Bp-100/80mmhg
PR-88bpm
Temp-98°F
GRBS-80mg/dl
I/O : 2250/1250ml
CVS - S1,S2 heard , no murmurs
RS - BAE + , NVBS
PA - Soft,Non tender
CNS- speech normal
RT LT
Tone : UL N N
LL N N
Power UL 4/5 4/5
LL 4/5 4/5
A:
? septic encephalopathy
To R/o pyogenic meningitis
k/c/o pulmonary kochs with ATT induced hepatitis
P:
IVF NS @30ml/hr
D4 inj.ceftriaxone 2g iv/BD
Tab.ursodeoxycholic acid 300mg RT/BD
Tab.ecosprin AV 75/10mg RT/OD
Inj.Optineuron IV/OD
Tab.PCM 650mg RT/Sos
monitor vitals
25/01/2023
UNIT 5
DR HIMAJA, PGY1
DR PAVANI, PGY2
DR SAICHARAN, PGY3
DR ABHINAYA, SR
DR AKASH, INTERN
DR HYNDAVI, INTERN
Ward DAY 5
AGE : 60 GENDER :M
S:
stools not passed
no fever spikes
no headache
O:
pt conscious, coherent, co-operative
Bp-110/70mmhg
PR-70bpm
Temp-98°F
GRBS-106mg/dl
CVS - S1,S2 heard , no murmurs
RS - BAE + , NVBS
PA - Soft,Non tender
CNS- speech normal
RT LT
Tone : UL N N
LL N N
Power UL 4/5 4/5
LL 4/5 4/5
A:
? septic encephalopathy secondary to urosepsis
k/c/o pulmonary kochs with ATT induced hepatitis
CKD with Anemia of chronic inflammation
P:
IVF NS @30ml/hr
D5 inj.ceftriaxone 2g iv/BD
Tab.ursodeoxycholic acid 300mg RT/BD
Tab.ecosprin AV 75/10mg RT/OD
Inj.Optineuron IV/OD
Tab.PCM 650mg RT/Sos
monitor vitals
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