65 yr old male with vomitings

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome

Name: K.G. Prasuna Reddy
Roll no. 59

I've 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 a diagnosis and treatment plan.



Following is the view of my case :


65 YR OLD MALE WITH C/O VOMITINGS SINCE 2 MONTHS
PT WAS APPARENTLY ASYMPTOMATIC TILL 2YRS. THEN HE COMPLAINED OF GIDDINESS AND WENT TO LOCAL HOSPITAL AND WAS DIAGNOSED WITH HTN. SINCE THEN, HE IS ON AMLODIPINE 5MG 
HE HAS VOMITINGS SINCE 2 MONTHS AFTER EATING, NON PROJECTILE, NO FOUL SMELL, NON BLOOD STAINED
NO H/O FEVER, COUGH BURNING MICTURATION, CONSTIPATION,
H/O WT LOSS ABOUT 10KG IN LAST 3 MONTHS

PAST H/O:
K/C/O HTN SINCE 2 YRS UNDER REGULAR MEDICATION (AMLO 5)
NOT K/C/O DM, CAD, CVA, EPILEPSY, TB, ASTHMA
PERSONAL H/O:
APPETITE NORMAL
DIET MIXED
SLEEP: ADEQUATE 
BOWEL AND BLADDER: REGULAR
NO KNOWN ALLERGIES

FAMILY HISTORY: NOT SIGNIFICANT 

PALOR+
NO ICTERUS, CYANOSIS, LYMPHADENOPATHY, EDEMA

VITALS AT ADMISSION:
BP: 110/80MMHG
PR: 88BPM
RR: 18CPM
SPO2: 98%AT RA

SYSTEMIC EXAMINATION:
CVS: S1,S2 HEARD
RS: BAE+
CNS: 
HMF INTACT
MEMORY: REMOTE INTACT, RECENT REDUCED
MMSE 25/30
GAIT SWAYING TO LEFT
NYSTAGMUS IN LEFT EYE
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
CEREBELLAR SIGNS:
DYSDIADOKINESIA: -
NYSTAGMUS IN LEFT EYE
TITUBATION -
HYPOTONIA-
INTENTIONAL TREMOR +
FINGER NOSE TEST +
FINGER FINGER TEST +
KNEE HEEL TEST ON BOTH SIDES +

P/A: SOFT, NON TENDER

INVESTIGATIONS:
HB: 14.9
TLC: 10,300
PLT: 3.56
RBC: 5.33
NA+: 130
K+: 3.9
Cl- 94
CA++: 0.93
LFT:
TB: 2.38
DB: 0.7
AST: 24
ALT: 13
TP: 6.9
ALB: 4.2
A:G: 1.53

SR CREAT: 1.3
BLOOD UREA: 56
SR OSM: 260
RBS: 90
BLOOD GRP: O+

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

TREATMENT:
17/12/22
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
 
18/12/22
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
GRBS 4TH HRLY

19/12/22
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
GRBS, BP 4TH HRLY

20/12/22
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
GRBS, BP 4TH HRLY 

Planning for MRI brain contrast


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