A CASE OF CEREBROVASCULAR ACCIDENT
MEDICINE CASE DISCUSSION
This is an E-log book to discuss our patient's
de-identified health data shared after taking his guardian's signed informed
consent. Here we discuss our individual patient 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 comments in comment box are most welcomed .
I have been given this case, in an attempt to solve
and understand the topic of "Patient's clinical data analysis”.
This has helped me develop my competency in reading and
comprehending clinical data including history taking, clinical findings and investigations.
The goal is to come up with a diagnosis and treatment plan.
PAVITRA BALDAWA
ROLL NUMBER -104
24th MAY, 2021
CASE DISCUSSION
Chief complaints:
A 60-year-old female who is a daily wage worker by occupation
came to the causality OPD on 1st may 2021 with chief complaints of loss
of consciousness (altered sensorium) for 30mins to 60 mins.
History of presenting illness:
The patient
was apparently asymptomatic the morning she came to the OPD, when she suddenly
fell after getting out of bathroom, it was associated with loss of consciousness
for 30min to 1 hour, the patient was taken to a local hospital and was said to
have high blood pressure and was given tab. Depin 5mg.Patient had involuntary
micturition while unconscious.
No history
of seizures, vomiting, fever.
Patient
presented with slurring speech.
Past history:
Patient is not a known case of hypertension, diabetes mellitus,
epilepsy, asthma, tuberculosis or CAD
No similar complains in the past
Personal history:
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel movements-regularBladder -involuntary micturition
Addictions-occasional consumption of alcohol
Allergies-no food and drug allergies
Drug history:
Patient was given tab.depin 5mg before coming to the OPD by
a doctor at local hospital
No known drug allergies
Family history:
Insignificant
General examination:
Examination was
done by a valid consent from the attender in daytime under proper sunlight and
a well-ventilated room.
The patient
was stuporous and not cooperative but coherent. The
patient was well nourished ,moderately build and not oriented to time ,place and person .
VITALS:
Pulse rate-102bpm
Bp-130/80mmhg
Respiratory rate-
20cpm
Temperature-Afebrile
GCS-4/15
GRBS-232mg/dl
Spo2-99% at
room air
Pallor: Absent
Icterus: Absent
Cyanosis: Absent
Clubbing: Absent
Koilonychia: Absent
Generalized lymphadenopathy:
Absent
Oedema: Absent
Pupils: Mild dilated ,slow reaction to light.
Systemic examination:
Respiratory system-
·
Bilateral air entry positive
Cardiovascular system-
·
S1 and S2 are normal
·
No abnormal heart sounds are heard
Central nervous
system-
·
level of consciousness-stuporous
· Speech-slurred
● No signs of meningeal infection or irritation
·
GCS-4/15
Per abdomen examination-
·
Soft and non-tender ,bowel sounds heard
Investigations
CT-scan-
acute haemorrhage in left cerebral hemisphere. Evidence of extension of haemorrhage
into 3rd ,4th and lateral ventricles.
Treatment given-:
Monitoring of vitals
Head end evaluation
Referral to higher centre:
Patient was referred to the higher centre
in need of neurosurgery intervention,
Advice at discharge:
Patient’s condition has been explained to
the patient attenders in their own understandable language and need for neuro
surgery intervention has also been explained .
In case of emergency immediately contact
your consultant, doctor or attend emergency department
Preventive care- avoid self-medication without doctor’s advice. Do not
miss any medication.
I would like to thank Rakesh Biswas Sir for providing us this
opportunity.
Thank you Saicharan kulakarni sir for guiding me.
QUESTIONS
What are the other treatment modality?
Does physiotherapy play a role ?
Describe the neurosurgery intervention in this case?
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