1801006098, long case

 THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S 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 AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT.   

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have 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 diagnosis and treatment plan.

A55 year old male patient came to opd with cheif complaints of slurring of speech since 11-03-23 and deviation of mouth to left side on    11-03-23.

HOPI:- Patient was apparently asymptomatic 7 days back then he developed slurring of speech  and deviation of mouth towards left side which were sudden in onset. 

No h/o drooling of saliva and ptosis.

No h/o trauma

No h/o difficulty of combing hair,mixing food, squatting,climbing stairs,    rolling in bed,lifting up neck.

No h/o of upper and lower limb weakness.

No h/o blurring of vision.

No h/o loss of consiousness.

No h/o altered sensorium.

Past history-no similar complaints in the past.

He is a known case of hypertension since 1 year and is on medication of atenelol and amlodipine(once a day ,morning after food 2tablets) 

History of perforation of tympanic membrane 15 years ago.

History of tuberculosis 21 years ago and took medication for 6 months.

PERSONAL HISTORY:- 

Diet-mixed

Appetite-normal

Sleep-reduced

Bowel and bladder movements-regular

Addiction -no current addictions(used to drink Toddy 20 years back but he stopped later)

Daily routine:- patient is farmer by occupation

He wakes up at 5 am and does his routine work and have his break fast(rice )at 8 am goes to work.

Has lunch at 1 -2 pm ( rice and curry) .

He reaches home at around 8 pm has dinner ( rice) and goes to sleep.

FAMILY HISTORY:-

Father is a known case of Diabetes , Hypertension and Tuberculosis and he passed away due to COVID.

Mother passed away due to breast cancer

Both the sons of the patient were also affected with tuberculosis at the same time

Both his sisters are known case of diabetes and Hypertension 

Brother , sister in law,and both their children were affected with tuberculosis.

Brother had history of stroke 3 years back.

GENERAL EXAMINATION:-

patient was consious ,coherent ,cooperative and well oriented to time place and person.

No pallor,no icterus,                  no cyanosis, no clubbing,        no  lymphadenopathy,no edema

Vitals-

       pulse rate-60 bpm

       Respiratory rate- 18 cpm   

Blood pressure-130/80mm of hg

            Temperature- afebrile

Systemic examination-

  Cns-   

Higher mental function -

Consiousness 

Oriented to time place and person

Speech-comprehension present,repetation present, no fluency

Memory- immediate,recent and remote present

No delusions or hallucinations

Cranial nerve examination:-

I- Olfactory nerve- sense of smell present

II- Optic nerve-direct and indirect light reflex present

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- direct and consenual light reflex, accomodation reflex present, no diplopia, no nystagmus, no ptosis.

V- Trigeminal nerve-      sensory: sensation present over face.

motor-Masseter, temporalis and pterygoid muscles are normal.

Reflex- Corneal reflex, conjunctival reflex and jaw jerk is present.

VII- Facial nerve- face is symmetrical 

Motor-forehead wrinkling present , nasolabial folds prominent on both sides.

Sensory- taste sensation on ant 2/3 of tongue present.

Reflex-corneal and conjunctival reflex present

VIII- Vestibulocochlear nerve- decreased hearing of the left ear ( rinner’s negative for 256 Hz and 512 Hz) and normal hearing of the right ear.

No nystagmus

IX- Glossopharyngeal nerve- palatal movements present and equal.

gag reflex present

 X- Vagus- palatal movements present and equal

XI- Accessory nerve- trapezius, sternocleidomastoid contraction present

XII- Hypoglossal nerve- deviation of tongue to right side.

Motor systerm:-

1) Bulk-              right       left

-appearnace   normal    normal

-palpation        normal    normal

-measurements

Upper limb -(arm) 29cm  29cm

              (Fore arm) 26cm  25 cm

Lower limb-( thigh) 49cm 49 cm

                    Leg)       31 cm  31 cm

2) Tone-

Upper limb-      normal  normal

 Lower limb-     normal  normal 

3) Power-

  Upper limb-

        Shoulder         5/5      5/5

            Elbow              5/5      5/5

         Wrist               5/5      5/5 

Lower limb-

       Hip-                   5/5     5/5

        Knee-                5/5     5/5

       Ankle-                5/5       5/5

        Leg-                    5/5      5/5

4) Reflex:

       Biceps reflex   2+         3+

        Triceps reflex  2+        2+

        Knee reflex      2+        2+

        Ankle reflex

        Plantar          flexion flexion

 SENSORY SYSTEM-

Crude touch -present

 Pain - present

Temperature- present

Fine touch- present

Tactile localisation-present

2 point discrimination-present

CEREBELLAR SYSTEM-

no gait ataxia

Nystagmus-no

Dysarthria-present

Intention tremor-absent

Limb coordination tests:

Finger nose test, heel shin test are normal.

dysdiadochokinesis

MENINGEAL SIGNS-

No neck stiffnes,no kernigs and brudzinsky sign

CVS-

Inspection- chest wall  appears normal in shape and symmetrical,no visible pulsations,scars,dilated veins.

PALPATION- apical impulse felt at 5 ICS medial to MCL.

AUSCULATION-s1 s2 heard nor murmurs heard

RESPIRATORY SYSTEM-

Inspection-chest wall normal shape and symmetrical movement with repiration, no dilated veins,no scars

Palpation- trachea central,Chest wall movements symmetrical, tactile vocal fremitus symmetrical.

Percussion- resonant,no pain and tenderness

Ausculation-normal vesicular breath sounds heard ,no addent sounds.

P/A- 

Inspection- abdomen round ,umbilicus in center not everted ,no visble sinuses and scar,no visible peristalsis,

Palpation-no pain and tenderness no organomegaly

Auscultation-bowel ssounds heard

Provisional diagnosis:

Acute cerebrovascular accident involving left mca territory.

Investigations:

Complete blood picture

 Haemoglobin:11.7

Peripheral smear: normocytic normochromic anemia

Red blood cells:3.86

Pcv:34.6

Platelet count:2.10

Total leucocyte count:5,100

Fasting blood sugar : 92 mg/dl

Serum creatinine :1.3 mg/dl

Blood urea 38 mg/dl

CUE:

Colour : pale yellow

Appearance : clear

Reaction :acidic

Albumin:nil

Sugar: nil

Bile salts and bile pigments : nil

RBC : nil

Crystals :nil

Casts : nil

pus cells:2-3

epithelial cells-2-3

Serum electrolytes 

Sodium: 145 mEq/L

Potassium:4.2mEq/L

Chloride:104 mEq/L

Calcium ionized:1.11 mmol/L

Ecg-

Carotid doppler

MRI REPORT

MRI IMPRESSION- infarcts in left internal capsule

Final diagnosis- acute cerbrovascular accident with small infarct in left internal capsule.

TREATMENT-

NS IV OD 

TAB. CLOPITAB 75 MG PO/OD

TAB. ECOSPRIN AV 75/10 PO