1801006174 - SHORT 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.

●CHIEF COMPLAINTS:-

A55 year old male patient came to opd with chief complaints of slurring of speech since 10days (11-03-23) and deviation of mouth to left side was observed by his wife on 11-03-23 and came to kims on 13-03-23 i.e.,8days ago

Date of admission:13/03/23

●HISTORY OF PRESENTING ILLNESS:- 

Patient was apparently asymptomatic 10days 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-Adequate

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.

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 regular and normal in volume and character

       Respiratory rate- 18 cpm, abdominothoracic type

      Blood pressure-130/80mm of Hg in left brachial artery

          Temperature- afebrile

●SYSTEMIC EXAMINATION:

 ◆CENTRAL NERVOUS SYSTEM EXAMINATION-  

Handedness-Right 

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 SYSTEM:-

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+         2+

        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-

-s1 s2 heard nor murmurs heard

RESPIRATORY SYSTEM-

-normal vesicular breath sounds heard ,no addent sounds.

P/A- 

Soft and no organomegaly,

bowel sounds 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

COMPLETE URINE EXAMINATION:

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:

MRI IMPRESSION- 

Infarcts in left internal capsule

CAROTID DOPPLER:

Carotid Doppler findings:

-Intimal thickening Of 2mm in Right CCA for a length of 1.5cm.

-7×1.6mm Atheromatous plaque noted in left CCA proximal to its bifurcation causing 20-30% of stenosis.

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

TAB.ORVAS-40

TAB.TINNICAR 200mg PO/BD