1801006188- 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.

A 55 year old male farmer by occupation resident of yadgirigutta came with chief complaints of

-deviation of mouth to left side since 7 days(11/3/2023)

-slurring of speech since 7 days

HISTORY OF PRESENTING ILLNESS:-

Patient was apparently asymptomatic 7 days ago then he had developed slurring of speech which was sudden in onset.On the same day his wife noticed deviation of mouth towards left side and was taken to local doctor for which he was given ORS but the symptoms has not subsided.

The next day his wife took him to another hospital for which he was given ORS.

On 13/3/2023 he came to our hospital.

At the time of presentation

Slurring of speech decreased

Slight deviation of mouth present

TIMELINE OF EVENTS:-

He is able to lift his hand, comb his hair, brush his teeth, able to wear his chappals, able to get up from bed

No history of vomiting,dizziness.

No history of blurring of vision

No history of drooling of saliva

No history of loss of consciousness

No drooping of eyelids

No history of difficulty in swallowing

PERSONAL HISTORY:- 

Diet-mixed

Appetite-normal

Sleep-reduced

Bowel and bladder movements-regular

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

Daily routine:

Patient is a farmer by occupation resident of yadgirigutta.

Patient wakes up at 5am in the morning and does his daily work and prays for an hour.

He has rice for breakfast by 8 am.

He goes to the fields along with his wife on scooty by 9am.

He has his lunch by 1pm.

In the evening they return from work at 6pm.

He goes for bath 

He has rice for dinner at 8pm and  prays for an hour.

He goes to bed at 10pm

PAST HISTORY:

No historyof similar complaints in the past.

Known case of Tuberculosis 15 years back-used medication for 6 months

He is a known case of hypertension since 1 year and takes medicines irregularly(Tab.Amlodipine 5mg)

No history of diabetes,asthma,epilepsy.

FAMILY HISTORY:-

His father is a known case of of diabetes, hypertension and tuberculosis and he passed away due to covid.

Both his sisters are known case of diabetes and Hypertension.

Brother had history of stroke 3years ago

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, coherent

Well 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:-         right              Left

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:-          2+.                 2+

             

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.

PER ABDOMINAL EXAMINATION:-

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:-

Cerebrovascular accident 

with acute infarct in left internal capsule

and acute infarct in left occipital lobe

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

Xray chest:-

Fever chart:-

Ecg-

Carotid doppler:-

MRI REPORT:-

MRI IMPRESSION- infarcts in left internal capsule

 Provisional diagnosis:-

   Cerebrovascular accident With acute infarct in left internal capsule and

acute infarct in left occipital lobe

TREATMENT-

INJ. OPTINEURON 1 AMP IN 500ML

NS IV OD 

TAB. CLOPITAB 75 MG PO/OD

TAB. ECOSPRIN AV 75/10 PO