Internship medicine posting

Medicine intern log

          Hello everyone, I'm a medical intern and recently started my medical posting.This blog is to share my experience and cases I came across during this period.

             60yr male came with

 cheif complaints of giddiness since 3 days.and visual hallucinations since 3 days

HOPI

    Pt was apparently asymptomatic 3 days back then he developed fever for 1 day for which he went to hospital and got treated and came back home ..then he developed giddiness only while walking , mostly swaying and unable to walk without support. 

Visual hallucinations are present ( seeing ciggretes in a plate asking wife to get them, perceives that his kids are sleeping with him and hiding something) 

 No slurring of speech ,no vomitings no blurring of vision , tinnitus, no diplopia.. 

60/M farmer previously now running tiffin shop since 10 years@miryalguda.chronic alcoholic,chronic smoker.k/c/o DM 2 since 9 years, regular medication and regular follow up 

      2 yrs back ,1st episode of involuntary movements of all 4 limbs associated with uprolling of eye balls, frothing, lasting for 5 -10 mins , started on anti epileptic drug but pt used to get repeated seizure activity for every 2/3 days-similar episodes .later on pt consulted neurologist in hyd and was put on 3 anti epileptic drugs ( lacosemide,carbamazepine,clobazam)continued for 4 months and stopped under medical supervision since then no seizure activity

    1 year back he went normally to work , suddenly developed weakness of both upper and lower limb..At that time slurring of speech and involuntary movements of   all 4 limbs present.loss of consciousness for about 1 min was present.. deviation of mouth to left side and post ictal confusion was present..? TIA .then they took him to the doctor,where MRI was done that showed subacute to chronic right capsuloganglionic bleed. Subacute to chronic

  

Neuropsychiatrist evaluation was done..

Past history

    K/C/O DM type 2  ...9 yrs back  pt  had fever For which they consulted a doctor and on routine investigations he was found having diabetes since then he is on oral hypoglycemic drugs and on regular follow up ...

Personal history

Diet -mixed

Appetite- normal

Sleep-adequate

Bowel movements-regular

Micturition- nocturia (5 to 6 times per night)

Addictions- chronic smoker ,smokes 10 beedies/day since 20 years

Occasional alcoholic  ( weekly once)

Family history

   Not significant

General examination

      Pt is conscious, coherent and co operative

Vitals  temp -afebrile 

             bp-160/110

            PR 68bpm regular in rate ,rythm and volume

             RR -20cpm

             Spo2 99

No pallor ,icterus ,cyanosis , clubbing, lymphadenopathy and pedal edema.

Systemic examination

 CNS 

Gait. 

Higher mental functions

Gcs 15/15

Oriented to time ,place,person.

Language

  Speech -fluency intact , repetation, naming,and comprehension intact.

Memory

   Recent memory is impaired

   Past memory is intact 

Cranial nerves- intact

Except 2nd and 7th 

2nd - left homonimous hemianopia

7th -deviation of mouth to right,left eyelid mild weakness,left facial hemiparesis UMN type.

 

 Motor system examination

 Bulk 

  UL.    Rt.     26    Lt. 27

  LL.     Rt.   39      Lt .39

Tone. 

Rt UL-normal

Lt UL-hypertonia

Rt LL -normal

Lt LL-normal

Power 

 UL.                  Rt                lt

Proximal. +4/5.          +5/5

Distal.        +5/5.           +5/5

LL.               +5/5.          +5/5

Reflexes.         Rt.         Lt

Biceps.           +3.         +3

Triceps.          +3.         +3

Supinator.     +3.         +3

Knee               +2.         +2

Ankle.           Absent.     Absent

Plantar.        Extensor.  Extensor

Superficial abdominal reflex : absent

Sensory examination

           Rt.            LFT 

Face    intact.     Decreased sensation over angle of mouth and cheek 

Chest trunk and limbs on left side- decreased sensation.

UL.     Intact.      Sup pain ,touch ,  proprioception t,lost.deep pain and pressure decreased

Meningeal signs

    Absent

Cerebellar signs 

       No past pointing ,no nystagmus,heel- sheen test negative ,no dysdiadochokinesia,random walking negative.

Respiratory system

Bilateral air entry present

Normal vesicular breath sounds heard

CVS examination

S1,S2 heard

No murmurs

Per abdomen

No tenderness,local rise of temperature.

Abdomen: scaphoid

Hernial orifices :free

Diagnosis

     Multiple acute infarcts in Medial temporal lobe, thalamus,right occipital lobe-Right PCA territory infarct..

      Old infarats in bilateral basal ganglian and right Corona radiata...

     Left homonimous hemianopia with left hemisensory loss.

     Tinea corporis et cruris et unguam..

    Vascular dementia..

     K/c/o DM 2 since 9 years on regular medication...

     K/c/o epilepsy 2 yrs back took medication for 1 yr then stopped under medical supervision...

    

Investigations

Fbs - 179

Plbs - 303

Hba1c-7.2

HMG 

Hb 12.9

Tot count 10,600

Neutrophils 54

Lymphocytes 40

Eosinophils 03

Basophils 00

Pcv 36.1

Mcv 79.9

Mchc 35.9

Platelet count 2.63

Smear normocytic normochromic

Fasting lipid profile

 Total cholesterol - 163

Triglycerides - 123

HDL - 46

LDL-92

VLDL -24

RFT 

Urea 29

Creatinine 0.7

Uric acid 2.8

Calcium 10.5

Phosphorus 2.6

Sodium 133

Potassium 3.2

Chloride 96

LFT 

Tot bilirubin 1.07

Direct bilirubin 0.30

SGOT 13

SGPT 10

ALP 228

Tot proteins 7.1

Albumin 3.9

A/G ratio 1.23

2D echo - Trivial TR+ ,no MR/AR

                  No RWMA , sclerotic AV ,no AS/MS

                 Good LV systolic function

                 Diastolic dysfunction+ no PAH/PE

Carotid Doppler scan  :normal

MRI

Treatment given:

1. Tab ecospirin (75mg/20 mg)/PO/OD

2.Tab pan 40 mg / PO/OD

3.Tab promethazine 25 mg/PO/TID

4.Tab glimi M1/PO/BD

5.Inj optineuron 1 amp in 100 ml/ NS/IV/OD

6.GRBS charting 6 the hrly

7. BP Charting

  

ADVICE AT DISCHARGE:

1.Tab ecospirin (75mg/20 mg)/PO/OD

2.Tab pan 40 mg / PO/OD

3.Tab promethazine 25 mg/PO/TID

4.Tab glimi M1/PO/BD

5.Tab multivitamin OD

https://drive.google.com/folderview?id=10v1jgj29C4LiDjT8K2CCajiSKxZkoH7y