Long case by H.T.NO: 1701006131; N JOSHUA PAUL

This is an a online e log book to discuss our patient de-identified health data shared after taking his guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

COMPLAINTS AND DURATION:

A 79 y/o male was brought to casuality with c/o cough since 1 & half month , fever since 10 days, difficulty in swallowing and h/o Aspiration pneumonia since one month

C/o altered sensorium since 3 days

HOPI

Patient is a known case of cva with left hemiplegia, DM type 2 , Hypertension, Thyroid disorders, and bronchial asthma.

Patient was apparently asymptomatic one and half month back when he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. Fever since 10 days -high grade. O/e Chills and rigors + (38 spikes).

Difficulty in swallowing. N/h/o vomiting, chest pain, loose stools.

PAST HISTORY

Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications I.e tab TELMA AM 40mg po/od. Tab zoryl mv , po/od

History of events:-

• 10 years back , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication.and after 1 year ,with regular check up he was found to be Hypertensive and started on antihypertensive medication.

• 7 years back, patient developed head ache at around evening 7pm and followed by vomtings, next day morning onwards patient became drowsy and cannot move his limbs and was taken to the hospital and found to have infarct and started on antiplatelets.

K/c/o CVA with left hemiplegia since 7 years.

K/c/o seizures disorder since 2 years for which on medications Tab levipil 500mg

K/c/o hypothyroidism since 5 years on thyronorm 25mcg.

• From 7 years onwards , patient was bedridden with foleys (changed every 15 days) and physiotherapy was done by his attenders daily, but there was no such improvement.

• 20 days back, from March 1st onwards ,patient developed slurring of speech and decreased responsiveness and cough ( mild ) and unable to clear the throat secretions and was taken to the hospital and was treated with antibiotics and patient was brought here for further evaluation.

PERSONAL HISTORY

Appetite lost,

Mixed diet

Bowel- constipated,

Bladder regular

No known allergies and Addictions.

i.e non alcoholic and non smoker

Family History- not any

Treatment history

•Tab TELMA AM 40mg po/od since past 10years

•Tab zoryl mv , po/od

•Tab levipil 500mg since 2 years