Gm case 6( prefinal exam case)

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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.

DATE OF ADMISSION:19/12/21

80 year old male patient presented to OPD with the chief complaints of involuntary bowel and bladder incontinence, loss of consciousness(30mins) 3 days back i.e., on(19/12/21).

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic till 4am on the day of admission

He got up from the bed to urinate in the bathroom at 4am

While walking to the bathroom the patient slipped and fell on the ground towards his back side of the body.

Sustained injury to the back and the head , loss of consciousness for 30mins later he regained the consciousness.

The patient then developed involuntary micturition, defecation, slurred speech after the fall and was presented to hospital.

No involuntary froth from the mouth is seen.

He was a farmer 10 years back. Whose daily past routine is to wakeup at 6am in the morning having some tea along with breakfast. Usually works in the farm till the evening. Later he completes dinner and sleeps by 9pm.

Daily routine (present) : not clear.

PAST HISTORY:

No history of hypertension, diabetes, asthma, tuberculosis 

No history of epilepsy

No history of CAD

One month back the patient has undergone cataract surgery to his left eye.

PERSONAL HISTORY:

appetite : normal.

Diet : mixed.

Bowels : irregular

Micturition : normal

The patient is an occasional alcoholic

The patient is a regular toddy drinker.

The patient smokes chutta (15-20 chutta's per day) since many years.

FAMILY HISTORY:

no relevant family history is seen.

TREATMENT HISTORY:

No relevant treatment history.

Cataract surgery one month back to his left eye.

GENERAL EXAMINATION:

The patient was confused, conscious, uncooperative, thin built.

No icterus

No pallor

No cyanosis

No lymphadenopathy

No clubbing

No edema .

VITALS:

Temperature : afebrile

BP : 170/120mmhg

Pulse: 90bpm

Respiration :20cpm

SPO2 at room 98%

LEFT EYE ( CATARACT SURGERY 1MONTH BACK)

RIGHT EYE:

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

No thrills 

No cardiac murmurs 

Cardiac sounds-S1,S2 heard.

RESPIRATORY SYSTEM:

Dyspnoea : No

Wheeze : No

Position of trachea : central

Breath sounds : vesicular.

PER ABDOMEN:

Shape of abdomen-scaphoid 

No tenderness 

No palpable mass 

Hernial orifices-normal 

No free fluid 

No bruits 

Liver ,spleen-not palpable 

Bowel sounds -yes 

CENTRAL NERVOUS SYSTEM:

Confused.

Slurring of speech.

Motor system : power , tone increased on right side

Sensory system : flexion movements due to pain.

GLASGOW'S SCALE: E4 M6 V5.

INVESTIGATIONS :

ECG :

ULTRASOUND:

MRI:

DIAGNOSIS:

ACUTE ISCHEMIC STROKE 2⁰ TO INFARCT in right frontal and right parietal region.