45 year old female in unresponsive state

 This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome. 

 I have 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, and investigations, and come up with a diagnosis and treatment plan.

CASE PRESENTATION:

Patient was bought to the casualty in drowsy but arousable state since morning. 

HISTORY OF PRESENT ILLNESS:

Patient works in a hotel as daily basis for cleaning dishes in hotel. 

Patient was apparently asymptomatic 12 years back, then she had nose bleed and went to the hospital  and diagnosed to have Hypertension and using medication since then. 

Patient had headache and weakness sometimes for which she used to go to hospital and high BP recordings were reported for which she used medications and symptoms subsided. 

Today morning she had sudden fall while doing her routine works and was taken to a hospital in Miryalaguda. She was drowsy but arousable since then.  There,  CT scan was done and was diagnosed with Intra-cranial hemorrhage and CVA (left capsulo ganglionic region) and her BP recordings were 210/110mmhg. Treatment was given (Inj. Lasix, Inj. Mannitol). She was referred to our hospital in drowsy but arousable state for further management.

Spontaneous eye opening (+), pupils dilates

No H/O ENT bleed

No H/O involuntary movements

No H/O trauma

Patient routine:

She wakes up 4:30 in the morning and does some Household works. She goes to hotel for work at 6am and eats breakfast there. She gets back home at 1pm and eats lunch. She sleeps or does some household work in meantime. She drinks milk in the evening. At 7pm she has dinner and sleeps at 9pm.

PAST HISTORY:

K/C/O HTN since 12 years using medication (T. Telma 40mg PO/OD)

Not a K/C/O DM-2, epilepsy, CVA, CAD

K/C/O TB 26 years back 

PERSONAL HISTORY:

Takes mixed diet, 

Normal appetite

Sleep adequate 

No Burning micturition 

No Addictions

No Allergies

No Significant Family History

O/E: 

Patient is c/c/c

No signs of Pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema of feet. 

Vitals:

Temp: 98.8F

BP: 160/90mmhg 

PR: 77bpm

RR: 20cpm

Spo2: 98% at RA

GRBS: 162 mg/dl

CVS: S1 S2 heard, No murmurs 

RS: BAE present, No added sounds

P/A: soft, non tender, bowel sounds heard

CNS: 

Tone-.       Right.    Left

UL-             N           N

LL-              N           N

Power-

UL-            2/5          4/5

LL-            3/5          4/5 

Reflexes- 

B-.               2+.          2+

T-.               2+.          2+

S-.               1+.          1+

K-.              1+.          1+

A-.              1+.          1+

Investigations:

Diagnosis:

CVA (left hemorrhage) with Right hemeparesis with 

?CAD - NSTEMI (LCX)

K/C/O HTN since 12 years

TB- 26 years back

Treatment:

IV fluid 0.9% NS @ 50ml/hr

Inj. 3% NaCl@ 10ml/hr

Inj. Sodium valproate 500mg IV/BD

Inj. Neomol 1gm IV SOS

Inj. Labetolol 10mg IV STAT

T. PCM 650mg RT SOS 

T. Cinod 10mg RT BD

Syp. Lactulose 15ml RT/HS

RT feed - 50ml water hourly 

                100ml milk with protein powder 2nd hourly

Physiotherapy