A 55 year old male with slurring of speech, difficulty in swallowing
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 patients 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 comment box is welcome.
A 55 year old male who was a mechanic by occupation came to the OPD on 31/5/23 with the complaints of slurring of speech, difficulty in swallowing since morning
Also c/o cough since 10 days
History of presenting illness:
Patient was apparently asymptomatic 10 days ago when he developed cough which is productive (attendant has informed that patient was having difficulty to spit out the sputum)
He developed slurring of speech and difficulty in swallowing since morning.
No H/o fever, cold
No H/o weakness in limbs
No H/o loss of consciousness
No H/o involuntary movements
No H/o giddiness
Past history:
Patient was diagnosed with hypertension 3 years ago and on regular medication(TAB. TELMA 40MG PO/ OD)
H/o CVA 3 years ago and 3months ago
H/o grade1 hepatic encephalopathy with pre renal AKI 7months ago
Personal history:
He has normal appetite, takes mixed diet, sleep is adequate, bowel and bladder movements are regular.
He used to consume alcohol (consumed for 30 years) but stopped 8months ago
He used to smoke cigarettes(1pack) but stopped 8 months ago
Daily routine:
Previously he used work as a mechanic.
He wakes up at 6am and freshen up, have tea, goes to work and comes home for lunch and returns to his workplace and comes home at 7 to 8 pm then have dinner and sleep.
He stopped working since 3 months, so he stays at home all the time now
General examination:
Patient is conscious, coherent
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
Vitals:
Afebrile to touch
Temp: 98°F
PR- 81 bpm
RR- 24cpm
BP- 110/80mmHg
SpO2- 96%
Systemic examination
CVS- S1 S2 present, no murmurs heard
RS-B/L air entry present, NVBS
PA- soft,non tender, bowel sounds heard
CNS -Pupils: B/L NSRL
Tone is decreased in right upper limb, normal in lower limb, increased in left upper limb and normal in lower limb.
Power: Right upper limbs: 0/5, Lower limbs: 1/5
Left upper limbs: 3+/5, Lower limbs: 4/5
Reflexes:
Biceps: Rt: + Left: +++
Triceps: Rt: + Left: ++
Supinator: Rt: + Left: ++
Knee jerk: Rt: + Left: ++
Ankle: Rt: + Left: ++
Plantar: Rt: Extensor Left: Flexor
Investigations
On 31/5/23
TLC:10,900 cells/ cumm
RBC: 4.39 million/cumm
PLT: 2.28lakh/cumm
PCV: 39.3%
Blood urea: 26mg/dl
Serum creatinine: 1.2mg/dl
Serum electrolytes:
Na+: 142 mEq/l
K+: 4.2mEq/l
Chloride : 104mEq/l
On 2/6/23
Hb:12.5gm/dl
TLC:12,900 cells/ cumm
RBC: 4.01million/cumm
PLT: 1.91lakh/cumm
PCV: 36.6%
Serum electrolytes:
Na+: 140mEq/l
K+: 4.0mEq/l
Chloride : 103mEq/l
ABG:
pH: 7.457
pCO2: 26.2 mmHg
pO2: 82.4 mm Hg
HCO3 : 21.2 mmol/L
On 3/6/23
Hb:13.5gm/dl
TLC:8,200 cells/ cumm
RBC: 4.30million/cumm
PLT: 1.71lakh/cumm
PCV: 39.6%
Serum electrolytes:
Na+: 136mEq/l
K+: 4.1mEq/l
Chloride : 107mEq/l
On 4/6/23
Blood urea: 55mg/dl
Serum creatinine: 1.1mg/dl
Serum electrolytes:
Na+: 143 mEq/l
K+: 3.8mEq/l
Chloride : 106mEq/l
Total bilirubin: 1.15 mg/dl
Direct bilirubin: 0.28mg/dl
SGOT:86 IU/L
SGPT:25 IU/L
ALP: 156IU/L
Total proteins: 6.3gm/dl
Albumin: 2.85gm/dl
A/G ratio: 0.83
On 5/6/23
Serum electrolytes:
Na+: 144mEq/l
K+: 3.8mEq/l
Chloride : 106mEq/l
Hb:11.9gm/dl
TLC: 14,000cells/ cumm
RBC: 3.78million/cumm
PLT: 1.94lakh/cumm
PCV: 35.3%
Treatment:
1.IVF NS AND RL @50 ml/hr
2.RT Feeds: 200ml milk + 2 scoops protein powder 4th hourly,
100ml water 2nd hourly
4.Inj. NEOMOL 1gm IV/SOS
5.Tab. ECOSPIRIN + CLOPIDOGREL 150 + ATORVASTATIN 40 mg RT/HS
6.Tab. PCM 650 mg RT/SOS
7.Tepid sponging
8.Oral suctioning 2nd HOURLY
9.Speech therapy,physiotherapy, early mobilization
Comments
Post a Comment