45 yr old with paraparesis

E-LOGS GENERAL MEDICINE

 

Roll no 04 

Hi, i am lasya, 5th Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent. This also reflects patients centered care and online learning portfolio. 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 patients clinical problems with collective current best evidence based inputs. Hope this will be informative!

* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required.

A 45yr old female patient came to casualty with complaints of

* Abdominal tenderness , distension and discomfort since 4 days 

* Decreased urine output since 4 days 

HISTORY OF PRESENT ILLNESS:

She was apparently asymptomatic 1 year ago when she developed fever , followed by pain in the back . She visited some hospital where they were told to have spinal degeneration and to have undergone surgery for it . But due to rising COVID cases they were not able to . She was on medication and 1 month later the symptoms subsided .

The patient developed fever 4 days back which got relieved by medication.Followed by burning micturition , headache, 5 to 6 episodes of vomiting.

She went to a local hospital ,she was kept on foleys catheter for passing urine  . she was told to have cystitis .

She also complained of abdominal discomfort (tightness) , distension and tenderness and difficulty walking since 2 days.

PAST ILLNESS :

not a k/c/o DM , hypertension, asthma , CAD , allergies 

PERSONAL HISTORY:

Diet - mixed

Appetite - decreased since 1 year

Sleep - decreased 

Addictions - no history of alcohol consumption or tobacco usage. 

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION: 

pallor -not seen

Icterus-not seen 

Cyanosis -not seen

Clubbing -not seen

Lymphadenopathy -not seen

Oedema -not seen

VITALS : 

Temperature -99°F

Pulse rate - 74/min

Respiratory rate -18/min

BP - 110/80

SpO2 - 96%

SYSTEMIC EXAMINATION:

CVS :

S1 S2 heard 

No thrills and murmurs 

RESPIRATORY SYSTEM:

BAE positive 

ABDOMINAL:

distended and tender.

CNS :

PROVISIONAL DIAGNOSIS:

Paraparesis secondary to L4 L5 lumbar canal stenosis.

INVESTIGATIONS :

ECG

MRI 

TREATMENT:

1) inj. METHYL PREDNISOLONE 1g IV /OD

2)inj.CEFTRIAXONE 2g IV/ BD

3)inj. OPTINEURON in 500ml NS IV /OD

4)IVF (NS /RL)@100ml/hr

5)inj.PAN 40mg IV/OD

6)inj.ZOFER 4mg 

7)BP /PR /RR /TEMP charting 4th hrly 

8)strict I/O CHARTING.