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65/m chronic vomitings since 2 months

 


This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians sign informed consent

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with n aim to solve those patient clinical problem with collect current best evidence based input

This Elog also reflects my patient centered online learning portfolio.

I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan

CONSENT AND DEIDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever 



Following is the view of my case

65 year/Male.  
resident of dupalli, yadadri district
Farmer by occupation 

65 year old male presented to casualty with chief complains of vomiting since 2 months

The patient is born and bought up in dupalli, he studied till 10th in dupalli.he wakes up by 5 am everyday and go to farm and takes care of two oxen since he was 15 years old. He sold his oxen one year ago after his knee deformity built an own home and watch tv in his free time 

The patient is apparently asymptomatic until 10 years back after which he had gradually progressing right knee deformity to which the family attenders assumed it is because of chickenguniya but haven’t used any medications

Since then Once in a while when he strain his knee he takes painkillers.

He is fine until two years ago, after which he had Giddiness and visited local doctor. At that time he was diagnosed with Hypertension and was prescribed amlodipine 5mg.

One year later on one fine afternoon while he was working in a farm he felt weak, and dizziness. He was taken to RMP doctor and was treated with medications unknown for his weakness and sent back home.the family members assumed it as BP fluctuations.

Two months ago he had right knee pain and visited local doctor and was prescribed pain killers and multivitamins for 10 days
After the course he felt giddiness and felt drowsy so he visited a local hospital in Choutuppal and was treated with medications unkown. He took one dose of those medication at home and vomited thereafter. 
He had mutton curry for lunch and 12 hours later he had one episode of vomiting.they assumed the vomitings were because of medications So stopped the medications but the vomitings were not resolved. And then they visited local hospital where he stayed for two hours and was administered NS along with iv injections unknown and hypertensives medications 
Next day he again had episodes of vomitings so after one week they went to hospital in city. There investigations were done and at that time he was diagnosed as having antral gastritis and advised to have soft foods
One week later he went to nursing home and got endoscopy and abdominal ct where no abnormalities were identified.
24 days later he came to our hospital for further management 

PRESENT HISTORY

vomitings since two months after eating usually at afternoons and sometimes at night after dinner. Non projectile, no foul smelling, non blood stained, scanty ,whitish in color

No H/O fever,cough,burning micturition, constipation,headache

H/o weight loss of 10kilos in three months

Also complains of inability to walk on his own since two months.

Vomiting image




PAST HISTORY

On June 2022 went to vemulokonda hospital  got tt and vaccinated for monkey scratch


Not a known case of DM/CAD/EPILEPSY/TB/ASTHMA 


PERSONAL HISTORY


married at age of 18, has two daughters 

No smoking and alcohol history

Bowel and bladder: regular

Diet: mixed non vegetarian 

Sleep: adequate

Appetite: normal

No known allergies


FAMILY HISTORY


Father died of TB 35 years ago

Mother has osteoarthritis and HTN since 1 year

No family history of Diabetes, CAD, Cancer, psychiatric illness, epilepsy 


GENERAL EXAMINATION:

PATIENT IS CONSCIOUS ,COHERENT AND COOPERATIVE.

ORIENTED TO  PLACE, PERSON BUT NOT TIME

NO PALOR ,ICTERUS, CYANOSIS, LYMPHADENOPATHY, EDEMA


VITALS AT ADMISSION:

BP: 110/80MMHG

PR: 88BPM

RR: 18CPM

SPO2: 98%AT RA

TEMP 98°F


SYSTEMIC EXAMINATION:

CVS: S1,S2 HEARD

RS: BAE+

CNS: 

HIGHER MOTOR FUNCTIONS: 

Consciousness - conscious

Oriented time x  place ✓  person ✓

Speech and language - n

Memory

- immediate - retention  decreased

                         Recall       decreased

recent     decreased

remote  ✓

Delusions and hallucinations absent 

MMSE SCORE 25/30

CRANIAL NERVES       RIGHT LEFT 

CN 1     Normal 

CN 2.    Field of vision    ⬇️.      ⬇️       

              Colour vision.    N.       N       

CN 3 4 6    Extra ocular movements. N.      ⬇️

                Pupil size        NSRL.   NSRL 

 Direct, Indirect reflex   N.          N.  

               Accomodation. N.        N

                Ptosis             absent.    Absent 

                 Nystagmus.  absent.     Present

CN 5.    Sensory and motor reflexes normal 

               Jaw jerk   Absent 

CN 7 ,8 ,9,10,11,12.  Normal on both sides

MOTOR: TONE NORMAL, POWER IN BOTH UL IS 5/5, IN BOTH LL IS 4+/5


CEREBELLAR SIGNS:

ATAXIA -  SWAYING TO LEFT

NYSTAGMUS PRESENT IN LEFT EYE TO THE LEFT 

NO DYSARTHRIA 

NO HYPOTONIA 

TITUBATION ABSENT 

NO INTENTION TREMOR 

PENDULAR KNEE JERK ABSENT 

UL   CORORDINATION 

FINGER NOSE TEST POSITIVE 

FINGER FINGER TEST POSITIVE 

(NO COORDINATION )

LL.  HEEL KNEE TEST

       Rt.          Lt

       ++.           - 

                                           RT.         LT

DYSDIADOKINESIA        +.             + 



MOTOR: TONE NORMAL, POWER IN BOTH UL IS 5/5, IN BOTH LL IS 4+/5

REFLEXES ON BOTH SIDES:

B ++

T ++

S +

K +

A +

P F



P/A: SOFT, NON TENDER



OUTSIDE INVESTIGATIONS






















Day 1 AMC











Day 2 AMC








Day 3







Day 4 AMC



44x41x42mm Peripherally enhancing thick irregular wall intra axial lesion in left cerebellar hemisphere extending into vermis 

Lesion is causing compression and displacement of 4rth ventricle to contralateral side with resultant mild dilatation of lateral and 3rd ventricle suggestive of acute hydrocephalus

Periventricular hyperintensity suggestive of transependymal sepage of CSF 


PROVISIONAL DIAGNOSIS:

1.Chronic vomitings since 2 months secondary to ?lt Cerebellar lesion compressing 4th ventricle ? Acute hydrocephalus secondary Mets? Primary brain malignancy

2.k/c/o htn since 2 yrs with b/l OA knee grade 4, lt more than rt

Day 1 treatment


INJ ZOFER 4MG IV TID

INJ PAN 80MG IN 50ML NS CONT IV INFUSION

IVF AT 75ML/HR

ORS 1 PACKET IN GLASS OF WATER IN SIPS

GRBS 4TH HRLY


Day 2 treatment 


INJ OPTINEURON 1AMP +100 ML NS IV OD

INJ ZOFER 4MG IV TID

TAB PAN D 40/30 PO/BD

IVF AT 75ML/HR

ORS 1 PACKET IN GLASS OF WATER IN SIPS

PROCTOLYTIC ENEMA

Day 3 treatment 


INJ OPTINEURON 1AMP +100 ML NS IV OD

INJ ZOFER 4MG IV TID

TAB PAN D 40/30 PO/BD

IVF AT 75ML/HR

ORS 1 PACKET IN GLASS OF WATER IN SIPS

TAB AMLONG 5MG PO OD

Day 4 treatment 


INJ OPTINEURON 1AMP +100 ML NS IV OD

INJ ZOFER 4MG IV TID

TAB PAN D 40/30 PO/BD

IVF AT 30ML/HR

TAB SHELCAL CT PO OD

TAB JOINTACE PO OD

D2 INJ LEVERA 500MG IV BD

D2 INJ DEXA 8MG IV TID








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