70year old male, headache since 20 days

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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 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 in the comment box are welcome.

I have been given this case to solve an attempt to understand the topic of "patient clinical analysis of data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan.

CASE DISCUSSION

 A 70 year old male Came with chief complaints of severe leftsided headache since 20 days associated with left ear tinnitus 


HOPI

Patient was an alcoholic for 10 years uses to consume 90 ml per day and stopped 6 years ago after he developed pedal edema and was relieved in a month with treatment (didn't have any records )

Patient had diminished vision 4 years back (more in the left eye) and had left eye surgery (pterygium excision)


Patient had fever 20 days back one episode of projectile vomiting with food as content then he had left sided headache sudden in onset more during night time ,pricking type of pain associated with giddiness intermittently . Not associated with photophobia, phonophobia

 Ringing sensation in the left ear associated with pain since 20 days , unable to walk without support since 20 days.


No chest pain , No palpitations, No polydypsia, No poly urea 

Nocturia - present 

Patient is found to be diabetic after admission 


N/k/o HTN, epilepsy, CVA,CAD

GENERAL EXAMINATION

  •Patient is examined in a well lit room after obtaining consent


•Patient is conscious, coherent, cooperative.

 Well built and well nourished.



•No Pallor,Icterus,clubbing, cyanosis, koilonychia, edema 


•VITALS 

Temp- Afebrile 

Bp-

PR- 76bpm

RR-18CPM

Spo2- 96%

GRBS : 240mg/dl

Systemic Examination:

CENTRAL NERVOUS SYSTEM
*Higher mental functions
Patient is conscious 
Oriented to time place and person
Well dressed, well behaved and in a 
Speech normal 
Memory: intact 

*Cranial nerves
Olfactory nerve: smells perceived 
Optic nerve: counting fingers 6m for left eye , right eye only light perception 
III, IV, VI: ocular motility normal, pupillary reflexes normal
Trigeminal nerve: jaw jerk present, corneal reflexes present
Facial nerve: intact
Vestibulocochlear nerve: normal sensory hearing
IX, X: no difficulty in swallowing
Accessory nerve: neck movements normal

*Motor system
muscle wasting present 
Normal muscle tone
Power: upper limbs- right 3/5.  Left-5/5
              Lower limbs- right 0/5. Left- 5/5
Reflexes.                         Right.              Left
             Supinator-           3.                       3
              Biceps.                 3.                       3
              Triceps.                3.                      3 
              Knee.                    3.                      3
              Ankle           Extensor.           Extensor
Coordination
        Finger to nose- present 
        Dysdiadochokinasea- present
       
Sensation- pain, temperature, proprioseption, vibration felt equally on both sides
Gait- unable to walk without support


RS- bilateral air entry present 


CVS : S1, S2 + no murmur, raised Jvp


P/A- soft and non tender

Examination findings : 

 Romberg's sign positive 

 Nystagmus negative 

 MMSC score -19 (uneducated)

 Raised JVP










Diagnosis:

Provisional : Headache under evaluation ?CVA

Denovo DM-2

Investigations : 

14th aug 

Fbs 253

Ppbs 306

HbA1c 7%


15th  aug 

Serum potassium- 3.9


17th aug

Fbs 188





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