General medicine case



 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / 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.





A 69 year old female was brought to the casuality with chief complaints of sudden onset of aphasia preceded by 2 episodes of vomiting and staring look 

History of present illness : 

She was apparently asymptomatic and coherent after then she had 2 episodes of vomiting and after which  she had difficulty in speech , generalised weakness , staring look at times ,difficulty in walking, walking with support  , patient was unable to recognize her family members. 

She had similar episodes of vomiting associated with weakness and disorientation 10 days back .  She became stable when she was given adequate food and fluids at home in 2 days . 

 Past history: 

No history of diabetes mellitus , hypertension , thyroid , epilepsy , seizures. 

No history of surgeries 

No history of fear , repetitive thought of action 

Personal history : 

Diet: mixed 

Non alcoholic

No smoking habits 

Appetite: decreased 

Sleep : decreased 

Family History: 

No similar history in the family 

Treatment history:

Not significant 

General examination:

30/9/2021:

Conscious (confused)

Intermittent coherence

Speech: response to few commands

2/10/2021:

Irrelevant talk intermittently

No fresh complaints

4/10/2021:

Irritability and irrelevant talk reduced

Patient is able to recognise family members at times and hallucinating behaviour decreased

Vitals:

30/10/2021:

BP: 120/60 mm Hg

PR: 84bpm

1/10/2021:

Temp: Afebrile

BP:110/60mm Hg

PR: 88 bpm

2/10/2021:

Temp: 97.5 F

BP: 120/60mm Hg

PR: 86 bpm (regular)

3/10/2021:

Temp 97.5 F

BP: 110/80mm Hg

PR : 88bpm regular

Systemic examination: 

1/10/2021: 

CVS: S1 S2 + no murmur

RESP System: Resonated breath sounds in B/L ISA

P/A - soft, no tenderness


2/10/2021:

CVS: S1S2 + No murmur

Rs: NVB1 decreased breath sounds in lt RSA

P/A soft, no tenderness

I/O 2200/1600 ml

GRBS 152 mg/dl


3/10/2021:

CVS: S1S2 + No  murmur

Rs: NVB1 decreased breath sounds in lt RSA

P/A soft, no tenderness

I/O 1550/1400 ml

GRBS 150mg/dl

Investigations : 

Complete blood picture : 


MRI : 


ECG : 


CBP , Serum electrolyte , LFT 


Other investigations: 





Medication history:


1/10/2021:
INJ.PAN 40mg i.v OD
INJ.ZOFER 16mg i.v SOS 
TAB. DOLO 650mg PO OD
INJ.OPTINEURO 650mg OD
INJ.MONOCEF 1g I.v OD

2/10/2021:
INJ. PAN 40mg I.v OD
INJ.ZOFER 4mg I.v SOS
TAB. DOLO 650mg PO SOS
SYP.ABROXY 10 mg PO TID
INJ.MONOCEF 1g I.v BD
TAB.ADMENTA 10mg PO OD
TAB.OLANZAPINE 5mg PO OD

3/10/2021:
INJ.PAN 40mg I.v OD
INJ.ZOFER 4mg I.v SOS
INJ.MONOCEF 1g I.v BD
INJ.DOLO 650mg PO SOS
SYP.AMBROXYL 10ml PO SOS
TAB.OLANZAPINE 5mg PO OD

4/10/2021:
INJ.PANTOP 40mg i.v OD
INJ.ZOFER 4mg i.v SOS
TAB.DOLO 650mg PO TID
SYP.AMBROXYL 10ml PO TID
INJ.MONOCEF 1g I.v BD
TAB.ADMENTA 10mg PO OD
TAB.OLANZAPINE 2.5mg PO OD
INJ.HALOPERIDOL 1/2amp/I.M/SOS(if patient is irritable)
INJ.LACTULOSE 15ml/PO/HS
IVF (NS and RL) 75ml/hr
1amp of OPTINEURON I.v OD

Provisional diagnosis: 

Wernickes Aphasia 

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