56 year old with C/O fever
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Here is a case I have seen: Unit II admission on 09/03/2021
DR. JAYANTH ( INTERN)
DR. AMULYA ( INTERN)
DR. SURYA PRADEEP ( INTERN)
DR. ASHA KIRAN ( INTERN)
DR. YAMINI ( INTERN)
DR. VAMSHI ( INTERN)
DR. ISMAIL (INTERN)
DR. PRADEEP ( PG 1st YEAR)
DR. NIKITHA ( PG 2nd YEAR)
DR. SUFIYA ( PG 3rd YEAR)
DR. SATISH ( PG 3rd YEAR)
Faculty : DR. VIJAYALAXMI
A 56 year old male came to casualty with c/o fever since 3days.
Generalised weakness, hoarseness of voice, difficulty in swallowing(more to solids) since 3 days.
Patient is asymptomatic 3days before, patient developed fever since 3days. Low grade, not associated with chills and rigors, relieved with medication. Fever associated with Generalised weakness.
Patient had decreased appetite since 5 days. Developed difficulty in swallowing (solids), taking only liquid diet since 5days.
Patient doing his own daily activities, no memory deficit, no irrelevant talking, exercissive sleepiness present.
No weakness of limbs 4days back, but patient is finding difficulty in walking since 1day, but walking with support.
H/O past illness:
K/C/O hypertension since 10years.
K/C/O Diabetes mellitus type 2 since 10years.
K/C/O CAD, CABG done 2014 (on regular medication) IHD, triple vessel disease, IWMI
(on nitroglycerin 2.5mg ; aspirin)
H/O smoking since childhood, chronic smoker; stopped sine 2014.
ON EXAMINATION
patient is conscious , coherent, cooperative
BP - 170/100mmHg ;
PR - 62bpm
RR- 17/min
CVS- S1 S2 heard . No thrills. No murmurs
RS - trachea central in position .
No dyspnea , no wheeze, vesicular breath sounds.
P/A - scaphoid in shape. No tenderness, no palpable mass. Normal hernial orifices. No free fluid and bruits.
CNS - conscious with normal speech. No signs of meningeal irritation.
Investigations:
CBP, CUE, RFT, LFT, ECG, FUNDOSCOPY, USG ABDOMEN, FBS, PLBS, HBA1C, CXR PA view, dengue NS1
Provisional diagnosis:
? CVA
K/C/O hypertension, dm since 10 years.
K/C/O CAD, post CABG
Treatment:
1. Ryles tube placement
2. Tab. Ecosprin 150mg PO OD
3. Tab. Atorvas 20mg PO H/S
4. Tab Nitroglycerin 2.5mg PO OD
5. Tab Glimi-M1 PO/BD
6. Tab Met-XL 25mg PO OD
7. Grbs charting 6th hrly
8. BP, PR, RR, SPO2 monitoring
9. Physiotherapy
On day 1 ; 10/03/2021 :
S:
Not passed stools since 3days.
O:
Patient is conscious, coherent, cooperative
BP: 150/90 mm hg
PR: 90@/ min
CVS: S1 S2 heard
RS: BAE+
P/A: SOFT
CNS:
CNS -. R. L
Tone UL. N. N
LL. N. N.
Power UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes. B. + +
T. - . -
S. + +
K. + -
A. - -
P. Flexor withdrawal
A: ? CVA
K/C/O DM2 AND HYPERTENSION since 10years
K/C/O CAD, post CABG
P:
1. Tab cilnidipine 10mg OD
2. Tab. Ecosprin 150mg PO OD
3. Tab. Atorvas 20mg PO H/S
4. Tab Nitroglycerin 2.5mg PO OD
5. Tab Glimi-M1 PO/BD
6. Tab Met-XL 25mg PO OD
7. Grbs charting 6th hrly
8. BP, PR, RR, SPO2 monitoring
9. Physiotherapy
On day 2 ; 11/03/2021 :
S:
Patient swaying to right side.
Increased regurgitation
O:
Patient is conscious, coherent, cooperative
BP: 140/90 mm hg
PR: 88/ min
CVS: S1 S2 heard
RS: BAE+
P/A: SOFT
CNS:
CNS -. R. L
Tone UL. N. N
LL. N. N.
Power UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes. B. + +
T. - . -
S. + +
K. + -
A. - -
P. Flexor withdrawal
A: ? CVA
K/C/O DM2 AND HYPERTENSION since 10years
K/C/O CAD, post CABG
P:
1. Tab cilnidipine 10mg OD
2. Tab. Ecosprin 150mg PO OD
3. Tab. Atorvas 20mg PO H/S
4. Tab Nitroglycerin 2.5mg PO OD
5. Tab Glimi-M1 PO/BD
6. Tab Met-XL 25mg PO OD
7. Grbs charting 6th hrly
8. BP, PR, RR, SPO2 monitoring
9. Physiotherapy
On day 3 ; 12/03/2021.
S: patient regurgitation symptoms decreased. Swaying to right side on standing reduced. Hoarseness of voice improved
O:
Patient is conscious, coherent, cooperative
BP: 160/80 mm hg
PR: 85/ min
CVS: S1 S2 heard
RS: BAE+
P/A: SOFT
CNS:
CNS -. R. L
Tone UL. N. N
LL. N. N.
Power UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes. B. + +
T. - . -
S. + +
K. + -
A. - -
P. Flexor withdrawal
A: CVA ACUTE INFARCT IN LATERAL MEDULLA
K/C/O DM2 AND HYPERTENSION since 10years
K/C/O CAD, post CABG
P:
1. Tab cilnidipine 10mg OD
2. Tab. Ecosprin 150mg PO OD
3. Tab. Atorvas 20mg PO H/S
4. Tab Nitroglycerin 2.5mg PO OD
5. Tab Glimi-M1 PO/BD
6. Tab Met-XL 25mg PO OD
7. Grbs charting 6th hrly
8. BP, PR, RR, SPO2 monitoring
9. Physiotherapy
On day 4; 13/03/2021
S:
Increased difficulty in swallowing to solids and liquids
Instability(giddiness) while walking decreased
Passed stools
O:
Patient is conscious, coherent, cooperative
BP: 140/90 mm hg
PR: 88/ min
CVS: S1 S2 heard
RS: BAE+
P/A: SOFT
CNS:
CNS -. R. L
Tone UL. N. N
LL. N. N.
Power UL. 5/5. 5/5
LL. 5/5. 5/5
Reflexes. B. + +
T. - . -
S. + +
K. + -
A. - -
P. Flexor withdrawal
A: CVA ACUTE INFARCT IN LATERAL MEDULLA
K/C/O DM2 AND HYPERTENSION since 10years
K/C/O CAD, post CABG
P:
1. Tab cilnidipine 10mg OD
2. Tab. Ecosprin 150mg PO OD
3. Tab. Atorvas 20mg PO H/S
4. Tab Nitroglycerin 2.5mg PO OD
5. Tab Glimi-M1 PO/BD
6. Tab Met-XL 25mg PO OD
7. Grbs charting 6th hrly
8. BP, PR, RR, SPO2 monitoring
9. Physiotherapy
10. Tab Clopidogrel 75mg PO OD
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