MEDICAL CASE
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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 competency reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
SARBESH MISHRA
Hall ticket No:1701006166
CASE DISCUSSION:
A 28 year old female came with chief complaints of Rodenticide poisoning 8 days back.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 8 days back. She had a fight with her in laws. Then she consumed Rat poison. The attempt was impulsive with guilt. After that she was brought to emergency department with headache, altered sensorium, decreased appetite and 1 episode of fever. She recieved conservative treatment. She was fine by next day evening. After 2 days she got discharged.
She was fine for 1 day and then she started getting severe headache, next day she had an episode of high grade fever for which she came to hospital and recieved symptomatic treatment after which she was completely fine.
HISTORY OF PAST ILLNESS:
Not a known case of
- HTN
- DM
- ASTHMA
- CAD
- EPILEPSY
- TB.
PERSONAL HISTORY:
- Diet- Mixed
- Sleep- Disturbed
- Appetite- Normal
- Bowel and bladder- Regular
- No addictions
- No known allergies
FAMILY HISTORY:
Irrelevant in this case.
GENERAL EXAMINATION:
Patient was examined in a well lit room, with adequate exposure and after taking consent.
Patient is conscious, coherent and co-operative.
She is well oriented to time, place and person.
Moderately built and nourished.
No signs of pallor, edema, icterus, cyanosis, clubbing, lymphadenopathy.
VITALS:
- Temperature : 100°F
- Pulse rate : 100 beats/min
- BP : 110/80 mm Hg
- RR : 15 cpm
- SpO2 : 97% at room air
- GRBS : 133 mg/dl
CLINICAL IMAGES:
SYSTEMIC EXAMINATION:
CVS :
RS :
- Bilateral air entry present
- Normal vesicular breath sounds heard
- No added sounds
GIT :
- Soft
- Non-tender
- No organomegaly
CNS :
1. Dominance - Right handed
2. Higher mental functions:
• conscious
• oriented to person and place
• memory - able to recognize their family members
• Speech - normal
3. Cranial nerve examination:
• 1 - can perceive well
• 2- Direct and indirect light reflex present
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present ( normal on both right and left eyes)
• 7- no deviation of mouth, no loss of nasolabial folds, no wrinkles on forehead
• 8- able to hear
• 9,10- position of uvula- central
• 11- sternocleidomastoid contraction present
• 12- no tongue deviation
4. Motor system:
Tone - normal time on right side(both UL,LL)
Normal tone on left side(UL,LL)
Bulk - Rt. Lt.
Arm 22cm. 22cm
Forearm 15cm 15cm
Thigh 42 cm. 42cm
Leg 24cm. 24cm
Power
Right. Left
UL 5/5 5/5
LL. 5/5 5/5
Reflexes Right Left
Biceps +2 +2
Triceps +2 +2
Knee jerk +2 +2
Ankle jerk +2 +2
Supinator +2 +2
Corneal reflex present on both sides
Light reflex present on both sides
(Direct and indirect)
MDCT SCAN BRAIN:
Normal without any anomalies.
PROVISIONAL DIAGNOSIS:
This is a case of 28 yr old female patient suffering from Rat poisoning (zinc phosphide poisoning).
TREATMENT:
1. INJ NAC 50MG/KG IN 500ML DNS
2. INJ PANTAPRAZOLE 40MG IV/OD
3. INJ ONDENSETRON 4MG Iv/OD
4. INJ NAC 1GM IV/OD
5. INJ VIT K 10MG IM STAT
6. CAP EVION 400MG PO OD
7. INJ SODIUM BICARBONATE 50MEQ /IV/STAT
8. INJ.SODA BICARB 1MEQ/KG/HR/IV
9. INJ.FUROSEMIDE 20MG/IV/BD
10. SYP SUCRALFATE 10ML POTID
11 .OPTINEURON 1 AMPOULE IN 500ML NS
SARBESH MISHRA
Hall ticket No:1701006166
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