55year old male H/o 12 days of fever,DENGUE IGM +ve With ACUTE ISCHEMIC STROCKE OF LEFT FRONTAL LOBE SECONDARY TO ? POST SPD TRANSFUSION ? DENGUE VASCLITIS RIGHT UMN FACIAL PALSY
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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.came to the hospital with
CHEIF COMPLAINTS of fever since 12 days and burning micturation since 12 days
HOPI
A 65 year old male ,apparently asymptomatic 12 days back then he had gradual onset of fever since 12 days initially high grade fever associated with chills, history of burning micturition on day 3 of illness. Patient sought for consultation at local Rmp and treated with oral medication. On day 4 of illness, the patient was brought to another local hospital for further management, there he was treated with iv Fluids for 3days.
As fever didn't subside, patient was shifted to another hospital; there he was treated with IV antibiotics and 1 unit of platelet transfusion was done in view of low platelet count. During the transfusion of platelet patient had chills. From next day of transfusion patient developed slurred speech and was reffered to our hospital in view of hemodialysis
Past history: n/k/c/o dm ,htn, asthama,epilepsy.
Histroy of platelet transfusion on 24/10/22
Personal history:
Diet : mixed
Appetite decreased
Bowel and bladder movements - constipation since 3 days
Consumes alcohol 180ml once in 2 weeks stopped since 6yrs
Smokes bedi 7 per day since age of 20 yrs
Family history- insignificant
General physical examination
Patient conscious, Oriented to time ,and persons but not to place on day of admission
pallor +
No icterus,CYANOSIS, clubbing, lymphadenopathy , oedema of feet
Temp :99°f
Pulse rate:86 bpm
Resp.rate- 16cpm
Bp- 130/80mmhg
Spo2-95%RA
GRBS:253mg/dl
SYSTEMIC EXAMINATION
CVS:
S1, S2 +, no thrills and murmurs
RS: BAE+, no added sounds heared
PER ABDOMEN- scaphoid, umbilicus central inverted , no scars and sinusess, all quadrants moving with respiration, soft , non tender ,bowelsounds +
CNS examination: patient was Conscious , and oriented to time and person but not place on the day of admission
Slurred speech on the day of admission but improved on day 2
All Cranial nerves intact , except for 7th cranial nerve
Deviation of mouth towards right
Tongue fasiculations present
Wrinking more on right than left
Sensory system examination:
B/l touch crude &fine, temperature, pain and vibrations present
Motar system examination
Reflexes were absent on the day of admission
Tone hypertonia in both upper and lower limbs
Right greater than left
DIAGNOSIS:
H/o DENGUE IGM +ve
With ACUTE ISCHEMIC STROCKE OF LEFT FRONTAL LOBE SECONDARY TO ? POST SPD TRANSFUSION
? DENGUE VASCLITIS
RIGHT UMN FACIAL PALSY
HYPERKALEMIA (resolved)
WITH NON OLIGURIC AKI ( resolved)
Mild anemia
WITH DENOVO DM II
CAD TO LCX ,LAD[6yrs ago]
Treatment:
INJ ZOFER 4MG IV/BD
INJ NEOMOL IF TEMP GREATER THAN 101 F
TAB ECOSPRIN 75 MG PO/ BD
TAB ATORVAS 40MG /PO/OD
TAB DOLO 65O MG PO/TID
TAB PAN 4O MG PO/OD
TAB METFORMIN 500 MG/PO /OD
SYRUP ARYSTOZYME 15ML/PO/ TID
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