56 Y OLD FEMALE WITH NECK STIFFNESS AAND GIDDINESS
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
56 Y old female R/o gazirnagar farmer by occupation came to casualty on 18.7.2021 at 3pm with complaints of
- giddiness from one day
- neck pain and stiffness from 18.7.2021 afternoon
- being irritable from 18.7.201 afternoon
Patient was apparently asymptomatic till today morning while brushing teeth she suddenly developed giddiness and fell down . She was attended by her husband who informed that she was unable to speak, unable to move her limbs. Slowly she gained strength and was picked up by her husband. She was taken to multiple hospitals before being brought to our hospital in a drowsy but arousable state. She was irritable and not compliant for examination.
She had h/o CRHD with severe calcific aortic valve for which replacement was done.
No h/o similar complaints in the past.
Not a k/c/o HTN, DM, asthma, epilepsy, TB.
Diet- mixed
Appetite- normal
Sleep- adequate
Bowel and bladder movements- regular
Addictions- occassional alcohol consumption
On examination
Patient is drowsy
Vitals- PR=112 bpm, RR= 18cpm, Temp= 101F,
BP= 150/110, GRBS= 142 mg/dl.
CVS- S1, S2 heard, no murmurs
RS- BAE+, NVBS heard, trachea central
P/A - Soft, non tender, bowel sounds heard.
CNS- Speech is normal.
Neck stiffness present.
Kernigs and Brudzinski signs are absent.
Cranial nerves- normal
Sensory system - normal
Motor system - normal.
Provisional Diagnosis- ?TIA, ? Meningitis.
Investigations
DAILY UPDATES
■19.7.2021
O/E patient is c/c/c
BP=140/100
PR=68bpm
CVS- S1, S2 +
RS- BAE+, NVBS
P/A - soft, NT
CNS
R L
Tone UL N N
LL N N
POWER UL 4/5 4/5
LL 4/5 4/5 Reflexes Biceps + +
Triceps + +
Supinator + +
Knee ++ ++
Ankle - -
Plantar withdrawl -
Rx
1.Tab. pan 40mg PO/OD
2. Tab. Ultracet 1/2 tablet QID
3. Tab. Ecospirin 75mg PO/OD
4. Tab. Dytor 10mg PO/OD
5. Tab. Dolo 650 mg po/qid.
■ 20.7.2021, 8am
Patient complains of nausea and vomiting, headache +, neck pain decreased.
Vitals:- BP=130/100
PR=80bpm
CVS- S1, S2 +
RS- BAE+, NVBS
P/A - soft, NT
CNS
R L
Tone UL N N
LL N N
POWER UL 4/5 4/5
LL 4/5 4/5 Reflexes Biceps + +
Triceps + +
Supinator + +
Knee ++ ++
Ankle - -
Plantar withdrawl -
Rx
1.Tab. pan 40mg PO/OD
2. Tab. Ultracet 1/2 tablet QID
3. Tab. Promethazine 25mg PO/TID
4. Tab. Dytor 10mg PO/OD
5. Tab. Dolo 650 mg po/qid.
6. Inj. Zofer 4mg IV/TID
7. Tab. Met-xl 12.5 mg po/od.
ENT REFERRAL
■ 20.7.2021, 9pm
BP=200/110mmhg was recorded.
Inj. Lasix 40mg/IV/STAT and Tab. Nicardia 20mg PO/STAT were given . Then bp reduced to 180/110mmhg.
CNS
B/L Pupils- Reacting to light
R L
Tone UL N N
LL N N
POWER UL 5/5 5/5
LL 5/5 5/5 Reflexes Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle - -
Plantar withdrawl -
ECG- Q waves in v1, T wave inversions in v1 to v5
Fundoscopy- normal.
CT brain-
CT BRAIN was done in view of the following relevant history....
She has very severe headache
( not relieved by NSAIDS)
Maybe like thunder clap headche.
and projectile vomitings not relieved on ondonsetron
Neck pain not relieved on NSAIDS
Which on examination has neck Rigidity...
she has Giddiness not relieved by Vestibular sedatives
DRUG H/o Acetrom
BP 200/120 mmHg
PR: 59 BPM
Fundoscopy was advised which was normal.
Plan:
1)Stop anticoagulation AND antiplatelets
2)Target BP <160/100 and MAP <110
21.7.2021
Diagnosis:- ?PCA stroke / ? IC bleed---SAH
K/c/o CRHD; severe calcific AS , Moderate LVD
Sx- AVR ( TTK - Chitra valve done in 2019).
K/c/o HTN since 2 yrs.
Rx-
1.Tab. pan 40mg PO/OD
2. Tab. Ultracet 1/2 tablet QID
3. Tab. Promethazine 25mg PO/TID
4. Tab. Dytor 10mg PO/OD
5. Tab. Dolo 650 mg po/qid.
6. Inj. Zofer 4mg IV/TID
7. Tab. Nimodipine 30 mg po/od.
DISCHARGE SUMMARY
•Diagnosis
SUB ARACHNOID HEMORRHAGEK/c/o CRHD, severe calcific AS , Moderate LVDSx- AVR ( TTK Chitra valve done on25/2/2019).K/c/o HTN since 2 yrs.
•Case History and Clinical Findings
56 Y old female R/o gazirnagar farmer by occupation came to casualty on 18.7.2021 at 3pm with complaints of- giddiness from one day- neck pain and stiffness from 18.7.2021 afternoon- being irritable from 18.7.201 afternoonPatient was apparently asymptomatic till today morning while brushing teeth she suddenly developed giddiness and fell down . She was attended by her husband who informed that she was unable to speak, unable to move her limbs. Slowly she gained strength and was picked up by her husband. She was taken to multiple hospitals before being brought to our hospital in a drowsy but arousable state. She was irritable and not compliant for examination.She had h/o CRHD with severe calcific aortic valve for which replacement was done.No h/o similar complaints in the past.Not a k/c/o DM, asthma, epilepsy, TB.Diet- mixedAppetite- normalSleep- adequateBowel and bladder movements- regularAddictions- occassional alcohol consumptionOn examinationPatient is drowsyVitals- PR=112 bpm, RR= 18cpm, Temp= 101F,BP= 150/110, GRBS= 142 mg/dl.CVS- S1, S2 heard, no murmursRS- BAE+, NVBS heard, trachea centralP/A - Soft, non tender, bowel sounds heard.CNS- Speech is normal.Neck stiffness present.Kernigs and Brudzinski signs are absent.Cranial nerves- normalSensory system - normalMotor system - normal.
•Investigation
PT -18 SEC
INR- 1.3
APTT - 35 SEC
2D ECHO : NO RWMA , NO AS/MS, SCLEROTIC AV GOOD LV SYSTOLIC FUNCTION DIASTOLIC DYSFUNCTION (+)
NO PAH/PE
MRI:-
ACUTE SUBARACHNOID HEMORRHAGE IN SULCI OF BILATERAL FRONTAL LOBES
&BILATERAL TEMPORAL LOBES INCLUDING SYLVIAN FISSURES
DIFFUSE CEREBRAL CORTEX
FOCAL NODULAR HYPERDENSE LESION MEASURING 8MM IN THE SUPRASELLAR CISTERN -ANEURYSM TO BE RULED OUT
MILD DILATATION OF VENTRICLES - EARLY HYDROCEPHALUS
•Treatment Given(Enter only Generic Name)
ON 19/7/21
TAB PAN 40MG/PO/ OD
TAB ULTRACET 1/2 tablet QID
TAB ECOSPIRIN 75mg /PO/OD
TAB ACITROM 2mg/PO/OD
TAB DYTOR 10mg /PO /OD
TAB DOLO 650mg /po/QID
ON 20/7/211.Tab. pan 40mg PO/OD2. Tab. Ultracet 1/2 tablet QID3. Tab. Promethazine 25mg
PO/TID4. Tab. Dytor 10mg PO/OD5. Tab. Dolo 650 mg po/qid.6. Inj. Zofer 4mg IV/TID7. Tab. Met-xl 12.5 mg po/oDON 21/7/21Tab. pan 40mg PO/ODTab. Ultracet 1/2 tab QIDTab. Promethazine 25mg PO/TIDTab. Dytor 10mg PO/ODTab. Dolo 650 mg QID/PO.Inj. Zofer 4mg IV/TIDTab. Nimodipine 30 mg OD/PO
Advice at Discharge
1) THE PATIENT NEEDS TO UNDERGO DIGITAL SUBTRACTION ANGIOGRAPHY AND
FOLLOWED BY TREATMENT DECISION ACCORDING TO NEUROSURGEON
2)TILL THE OPINION OF NEUROSURGEON ,
TAB.NIMODIPINE 30MG OD/PO
STOP ALL ANTIPLATELETS AND ANTICOAGULANTS
Follow Up
THIS IS CASE OF 56 YR OLD FEMALE CAME WITH COMPLAINTS OF SUDDEN LOSS OF
CONSCIOUSNESS FOR ABOUT 10 MIN. ASSOCIATED WITH SEVERE HEADACHE AND
GIDDINESS WHICH WAS NOT RELIEVED BY NSAIDS ,VESTIBULAR SEDATIVES . PATIENT HAD HISTORY OF AORTIC VALVE REPLACEMENT 2 YRS BACK AND SHE WAS ON TAB. ACITROM 1MG AND ANTIPLATELETS . ON FURTHER EVALUATION , CT SHOWED SUB ARACHNOID HEMORRHAGE . TO RULE OUT ANEURYSM , PATIENT WAS REFERRED TO HIGHER CENTRE FOR DIGITAL SUBTRACTION ANGIOGRAPHY AND FOR ANY INTERVENTION LIKE CLIPPING .
THE CONDITION OF THE PATIENT WAS CLEARLY EXPLAINED TO THE ATTENDANTS IN THEIR OWN UNDERSTANDABLE LANGUAGE.
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