INTERN'S LOG BOOK
As a part of our internship , we make a log of what we do in the department day to day to assess how much we have learnt .
Here I am presenting you an interesting case ..which is under evaluation.
I am going to provide the details of the case along with the investigations we have sent and treatment given.
CASE HISTORY
My patient a 45 yr female , a housewife
Presented with complaints of
-headache for the past 2 years
-B/l lower limb weakness for the past 5 months
- h/o - multiple body pains, disturbed sleep, auditory hallucinations , double vision
Diagnosed as depression without psychotic features
She was on Bulotin , Esihan's plus for 1 week
CT - done -small calcific foci in left high parietal region
She had a sudden fall ..
and slurring of speech present..swaying present
With NO loss of consciousness , seizure activity.
Diagnosed as Ischemic stroke
-Complaints of swaying to right/left side unable to get up from bed, giddiness on lying down, standing, walking
NO -dysphagia
- drooling of saliva
- difficulty in chewing
- hearing difficulties
PAST HISTORY
K/C/O - hypothyroidism -on Tab.Thyronorm 25 mcg/PO/OD for the past four months
H/O-uterine prolapse 20 yrs ago and hysterectomy done.
NO h/o - DM, HTN , Asthma , Epilepsy ,TB, CAD
NO allergies
DRUG HISTORY
Nortryptiline
Cerebroprotein
MVT
Ecosprin
Clopitab
Atovastatin
NSAIDS
PERSONAL HISTORY
Housewife
Appetite -N
Mixed diet
Bowel and bladder - regular
No addictions
MENSTRUAL HISTORY
Menarche-15 yrs
Normal cycles
No dysmenorrrhea
MARIETAL HISTORY
She was married at 18 yrs
3 degree consanguinity
OBSTETRIC HISTORY
1 st child- spontaneous vaginal delivery - 25 yrs old
2 nd child-vaginal delivery, died at 1 month of age due to unknown reason
3rd child - died at the age of 21 due to kidney failure
EXAMINATION
General Examination
Patient is conscious, coherent and cooperative
Moderately nourished and built
Afebrile
Pallor mild
Icterus -
Cyanosis -
Clubbing -
Lymphadenopathy -
CNS Examination
Higher mental functions-
Consciousness present
Orientation to time ,place and person present
Memory -immediate ,recent and remote present
Speech and emotions -intact
Cranial nerves -
Right 3 rd and 6 the cranial nerves effected
Facial nerve-effected on left side
Motor System-
Tone -hypotonia present in rt upper and lower limbs
Power -
UL . Rt. Lt
-4/5. -4/5
LL
5/5. 5/5
Gait - ataxic gait
Reflexes -
Superficial reflexes - abdominal reflex - absent
Plantar extensor reflex present
Deep reflexes - exaggerated
Sensory system
Superficial -
Touch , pain , temperature perception normal
Deep -
Pressure, position sense normal
Cortical -
Tactile localization , 2 pt discrimination present
Meningealirritation absent
CVS Examination S1 S2 heard..no murmers
Respiratory Examination -NVBS
P/A - Normal
INVESTIGATIONS :
-CBP - Hb- 11.2 gm/dl
-RBS -93mg/dl
-ECG
-CRP -1.2 mg/ dl
-ESR - 60 mm/1st hr
-SERUM SODIUM -146mmol/lt
-SERUM CREATININE -0.9 mg/dl
-APTT -34 sec
-PT -17 sec
-MRI
-CAROTID DOPPLER
TREATMENT :
1. Ink.Methyprednisolone 1gm in 100 ml NS OD
2. Inj.Zofer 4 mg /i.v /sos
3. Tab.PCM 650mg/PO/sos
4.Tab.Atorvastatin 20 mg/PO
5. Physiotherapy of right upper limb and lower limb
6. BP charting 4 the hrly
PROVISIONAL DIAGNOSIS:
1. NMO
2. Multiple sclerosis
3. Neuro - Behcet's disease
4. Vasculitis
5. Neurosarcoidosis
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