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-
TREATMENT-
NS IV OD
TAB. CLOPITAB 75 MG PO/OD
TAB. ECOSPRIN AV 75/10 PO
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