1801006171 short case

This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident 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

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

Case discussion 

A 50 year old male presented to the casualty with weakness of right upper and lower limbs since the morning of 13/3/23 4am. With slurring of speech and deviation of mouth to the left side. 

History of presenting illness 

Patient was apparently asymptomatic 1 month back, he later developed giddiness followed by a fall. He was diagnosed with hypertension( HTN) to which he used medication for 20 days and stopped 10 days ago. 

He was asymptomatic until 17 th March 2023when he noticed weakness in his right upper and lower limbs while going to the washroom.

slurring of speech also seen

 Symptoms were sudden in onset and quick in progression.  

There is history of (H/O) trauma

Upper limb- Patient has difficulty in combing hair, difficulty in buttoning and unbuttoning.

Lower limb- not able to stand due to swaying towards right side

There is no H/O difficulty in swallowing, giddiness, headaches, nausea, vomiting, drug intake, chest pain, drug intake, tingling sensation of effected limbs. 

no history of difficulty in closing eyes , lips, able to sense taste and able to move neck and tongue

Past history 

30 years ago sustained a fracture in the right elbow.

Diagnosed with HTN one month back.

Patient started using medication for hypertension for 20days and stopped for next 10days.

No H/O diabetes mellitus, epilepsy, tuberculosis, coronary artery disease, thyroidal illness, HIV, malignancy, fever, drug intake

Personal history 

Diet- mixed

Appetite- normalà

Bowel and bladder- regular

Sleep- adequate

Addictions- The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days.

He consumes alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago after the death of his daughter’s husband.he drinks around 90 ml per day

Family history-

 no relevant family history 

Treatment history

Patient took treatment for hyper tension

General examination 

Patient is examined after taking consent

Patient is examined in a well lit room

Patient is conscious, coherent and cooperative 

Well built and nourished

pallor: absent 

Icterus: absent

Cyanosis: absent

Clubbing:absent

Lymphadenopathy: absent 

Edema: absent 

Temperature: 98°F  

Pulse:60 beats/ minute 

Blood pressure: 140/80mmHg 

Respiratory rate: 14 cycles/minute 

No involuntary movements 

No abnormal neck swellings 

No neck stiffness present

Systemic examination

CENTRAL NERVOUS SYSTEM

Higher mental functions

Patient is right handed 

Patient is conscious 

Oriented to time,place and person

Well dressed, well behaved and in a good mood

Speech slightly slurred, langu age understandable 

Memory is intact 

Cranial nerves

Olfactory nerve: smells perceived 

Optic nerve: counting fingers 6m

III, IV, VI: ocular motility normal, pupillary reflexes normal

Trigeminal nerve: jaw jerk present, corneal reflexes present

Facial nerve: mouth deviated to the left side

Vestibulocochlear nerve: normal sensory hearing

IX, X: no difficulty in swallowing

Accessory nerve: neck movements normal place and person

Motor system

No muscle wasting

Normal muscle tone

Power: upper limbs- right 3/5. Left-5/5

              Lower limbs- right 0/5. Left- 5/5

Reflexes.                             Right.      Left

             Supinator-                3.               3

              Biceps.                  3.                 3

              Triceps.                 3.                 3

              Knee.                      3.                3

              Ankle             Extensor       Extensor

Coordination

        Finger to nose- present on right side

        Dysdiadochokinasea- present on right side

        Knee to heel- uncoordinated on the right side

Sensation- pain, temperature, proprioseption, vibration felt equally on both sides

Gait- unable to walk without support, dragging legs

Rombergs test- couldn’t be elicited

CARDIOVASCULAR SYSTEM. 

*Inspection- normal shape, bilaterally symmetrical, no percardial bulge, no engorged veins

*palpation- apical beat felt at 5th inter coastal space, no additional pulsation felt, no thrills felt

*percussion- heart borders noted

*auscultation- S1 and S2 heard. No additional heart murmurs

ABDOMEN

*inspection- flat abdomen with no distension, no engorged veins visible, skin over abdomen normal, umbilicus central, hernial orifices normal, external genital normal.  

*palpation- no tenderness present, temperature to touch normal, no abnormal swellings. 

*percussion- tympanic sound with dullness over solid organs

*auscultation- bowel sounds heard.

RESPIRATORY SYSTEM 

*inspection-chest normal shape and bilaterally symmetrical

*palpation-trachea midline, chest movements symmetrical, tactile and vocal fremitus felt

*percussion- no dullness present bilaterally 

*auscultation: Normal vesicular breath sounds heard, no added sounds. 

Diagnosis: Cerebrovascular accidentwith right hemiparesis. 

Investigations:

Haemogram:

Haemoglibin 13.4

Total lecucocyte count 7,800

Red blood cells 4.45

Platelets- 3.01

Complete urine examination 

Pale yellow clear

Acidic

Trace albumins

Pus cells 3-4

Epithelial cells 2-3

Sugars nil

Thyroid function tests 

T3 0.75

T4 8

TSH 2.18

 

Chest x ray

Ct scan head

Mri of brain

Renal function test

Urea: 19mg/dl

Serum. Creatinine: 1.1mg/dl

S. Na+: 141 mEq/L

S. K+:. 3.7 mEq/L

S. Cl-: 1.02 mmol/L

FASTING BLOOD SUGAR: 114mg/dl

Diagnosis

CEREBROVASCULAR ACCIDENT WITH RIGHT HEMIPARESIS WITH ACUTE INFARCT IN POSTERIOR LIMB OF LEFT INTERNAL CAPSULE

K/C/O HTN SINCE 1 MONTH

Treatment: 

1. TAB. ECOSPRIN 150 MG PO/STAT

2. TAB. CLOPITAB 150 MG PO/STAT

3. TAB. ATORVAS 80 MG PO/STAT

4. PHYSIOTHERAPY OF UPPER AND LOWER LIM

5. I/O CHARTING

6. VITALS MONITORING

7. INJ. OPTINEURON IN 1 AMP IN 500ML NS IV/OD