A 60 YEAR OLD MALE WITH COMPLAINTS OF GIDDINESS
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 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 on the comment box"
This is case of 60 year old male came to casualty with chief complaints :
Patient c/o giddiness since 6days
C/o headache since 6days
Hopi:
Patient was apparently sympatomatic 10 years back then he had stomach ache for which he was referred to our hospital. Then he was diagnosed with intestinal perforation and he was operated and discharged after 6 days.
4yrs back he fell in drainage pit and got ankle fracture. And he got nail plate operated and removed after 1 month
6 days back pt has giddiness on walking and vomiting 5-6episodes nin projectile, non bilious, food as content.
Headache for which he was taken to near by govt hospital amd treated symptomatically for 5days amd referred to higher centre.
Past history
Not k/c/o DM,HTN,epilepsy, asthma, CAD
General examination
Patient is conscious, coherent,cooperative
No PICKLE
Vitals:
Temperature: 98 F
Bp 130/80 mm hg
PR 82 bpm
RR. 16cpm
GRBS 108mg/dl
CVS Examination :
Heart sounds: s1 s2 heard
No murmurs
Respiratory examination :
NVBS
Per abdomen:
Non tender, soft
CNS Examination:
Level of consciousness: conscious
Speech: normal
No signs of meningeal irritation
CRANIAL NERVE examination :
C1 normal
C2 normal
C3 vision decreased in left eye
C4 normal
C5 normal
C6 normal
C7 normal
C8 normal
C9 normal
C10 normal
C11 normal
C12 normal
MOTOR EXAMINATION:
UL LL
1.Bulk
Rt normal/no wasting normal/no wasting
Lt normal normal
2.Tone
Rt normal normal
Lt normal normal
3.power
Rt 5/5 5/5
Lt 5/5 5/5
4.reflexes biceps triceps supinator ankle knee
Rt ++ ++ ++ ++ ++
Lt ++ ++ ++ ++ ++
Sensory examination:
fine touch and Crude touch normal
Pain normal
Temperature normal
Propriception normal
Vibration normal
Cerebellar function:
Finger nose test :impaired
Finger finger test :impaired
Nystagmus no
Knee heel normal
Dysdiadochokinesia intact
Rombergs :positive swaying to right side
Provisional diagnosis :
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
INVESTIGATIONS :
MRI BRAIN :
Ecg :
Rbs -121 mg/dl
Blood urea :22 mg/do
S.elctrolytes :
Na + :139 meq/ml
K+ :4.5 meq/ml
Cl- :98 meq/ml
Hemogram:
Hb :18.1 gm /dl
TLC: 10000 cells /cumm
Plt : 3.38 lks
N/l/E :60 /26/5
LFT :
Total bilirubin:1.48 mg /dl
Direct bilirubin:0.52 mg/do
AST 26 IU
ALT 27 IU
ALP 124 IU
Total protein 7.1 gm /dl
Albumin 4 gm /dl
Treatment :
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
5.TAB PROMETHAZINE 25MG PO BD
SOAP NOTES :
DAY 1
AMC BED NO 6
S:
Complaints of GIDDINESS
Rombergs postive swaying to right
O:
On examination
Patient Is C/C/C
No PICKLE
BP :120/80 mmhg
PR :82 BPM
RR:17CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
AMC BED NO 6
Day2
S:
GIDDINESS SUBSIDED
NO FRESH COMPLAINTS
O:
On examination
Patient Is C/C/C
No PICKLE
BP :120/80 mmhg
PR :86 BPM
RR:16CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
AMC BED NO 6
Day 3
S:
No new complaints
O:
On examination
Patient Is C/C/C
No PICKLE
BP :120/80 mmhg
PR :84 BPM
RR:17CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
AMC BED NO 6
Day 4
S:
Complaints of vomitings 4episodes
O:
On examination
Patient Is C/C/C
No PICKLE
BP :110/80 mmhg
PR :87 BPM
RR:17CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
5 TAB PROMETHAZINE 25MG PO BD
AMC BED NO 6
Day 5
S:
Complaints of vomitings and loose stools 3 episodes
O:
On examination
Patient Is C/C/C
No PICKLE
BP :120/80 mmhg
PR :86 BPM
RR:16CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
AMC BED NO 6
Day 3
S:
No new complaints
O:
On examination
Patient Is C/C/C
No PICKLE
BP :120/80 mmhg
PR :84 BPM
RR:17CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
AMC BED NO 6
Day 4
S:
Complaints of vomitings 4episodes
O:
On examination
Patient Is C/C/C
No PICKLE
BP :110/80 mmhg
PR :87 BPM
RR:17CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
5 TAB PROMETHAZINE 25MG PO BD
AMC BED NO 6
Day 5
S:
Complaints of vomitings and loose stools 3 O:
On examination
Patient Is C/C/C
No PICKLE
BP :120/90 mmhg
PR :92 BPM
RR:16 CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
5.TAB PROMETHAZINE 25MG PO BD
DAY 6
AMC BED NO 6
S:
vomitings and loose stools subsided
No fresh complaints
O:
On examination
Patient Is C/C/C
No PICKLE
BP :110/80 mmhg
PR :88 BPM
RR:16CPM
SPO2 :98 ON RA
A:
ACUTE ISCHEMIC STROKE ( cerebellar infarct)
? PICA
P:
1.TAB ATORVAS 80 mg PO HS
2.TAB PAN 40 MG PO OD
3. TAB VERTIN 8 mg TID
4.TAB STROCIT PLUS 800 mg/500mg PO BD
5.TAB PROMETHAZINE 25MG PO BD
