75 YRS OLD FEMALE WITH CVA

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

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

Team:

Interns-

M Supriya

Mohitha

K Sowmya

Sanjay

Amrutha


Dr.Druga Krishna PGY1

Dr.Ajith Kumar PGY2

Dr.Laxma Reddy PGY3

Dr.Manasa PGY3

Dr.Vijaya Lakshmi (Ast.Prof.)

C / o altered sensorium 
Unable to speak
Unable to move her upper and lower Limbs since  6 o'clock in the evening yesterday
Patient had history of toddy intake in the afternoon yesterday after which she unable to move her right upper limb and lower Limbs ⁶6ťshe unable to speak ok or response two daughters commands six o'clock in the evening yesterday then she was taken to to local Hos6pital where inhalation and cough syrup was given following which she was referred to KIMS for further evaluation
Past history
No  H/ o DM,HTN,CVA,ASTHMA,76TB,EPILEPSY 
Personal history 
 Toddy drinker daily
-General examination:-
pt was unconscious
pt was thin built 
No signs of Icterus, cynosis,clubbing lymphedenopathy, Generalized edema 
GCS:-E1V1M5
CNS-
Higher mental functions-cant be elicited 
Cranial nerves-cant be elicited
motor system-.                    R.                      L.   
power                  UL-.          1/5.              4/5.    
                            LL-.           2/5.              4/5.  
 Tone-.                 UL-.     Hypotonic      Hypertonic
                            LL-.       Hypotonic      Hypertonic
reflexes-.                                   R.                      L.   
                biceps-.                     1+.                   1+.  
                triceps-.                    -                      -
                supinator-.                -                       -
                knee.                          -                      1+
               ankle-.                         -                        -
               plantar -          extension             extension












Sensory system-cant be elicited 
Cerebellar functions-cant be elicited  
Cvs:-s1,s2+

R/s:-BAE+
P/A:-soft,no organomegaly 




Treatment:-
On the day of admission 
1.inj.CEFTRIAONE 1gm/IV/BD
2.inj.OPTINEURON 1amp in 100ml NS/IV/OD
2.inj.PAN 40mg IV/OD
DAY 2
1.TAB ASPIRIN 75MG OD/PO
2.TAB ATORVASTATIN 40MG OD H/S
3.INJ.CEFTRIOXONE 1GM IV/BD
4.INJ.PAN 40 MG IV/OD
5.INJ OPTINEURON 1 AMP IN 100ML NS IV/BD
Day 3

1.TAB ASPIRIN 75MG OD/PO
2.TAB ATORVASTATIN 40MG OD H/S
3.INJ.CEFTRIOXONE 1GM IV/BD
4.INJ.PAN 40 MG IV/OD
5.INJ OPTINEURON 1 AMP IN 100ML NS IV/BD
pt was shifted to air bed to prevent bedsores









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