1801006189. - 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.

 55 year male patient farmer by occupation presented with cheif complaints of: 

- Slurring of speech since 10 days

-deviation of mouth towards left side since 10days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic  10 days ago then he developed slurring of speech  and deviation of mouth towards left side which were sudden in onset non progressive and no loss of sensation over limbs and face.Patient is has no complaints at night and sleeps peacefully.WAKES up in the morning with complains of stroke facing difficulty in speaking (he is able to talk but opposite person couldnot understand) difficulty in eating . 

No h/o trauma

No h/o drooling of saliva

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 

Patient is a known case of hypertension since 1 year.History of perforation to the tympanic membrane 15 years ago.History of tuberculosis 21 years ago and took medication for 6 months.

PERSONAL HISTORY 

Patient takes mixed diet,appetite is decreased,bowel and bladder movements are normal.Addictions : Patient has NO addictions at present,but 20 years ago he used to consume TODDY.No known allergies

DAILY HISTORY 

He wakes up at 5 am and does his routine work and have his break fast at 8 am goes to work.He will Have his lunch at 1 -2 pm.He reaches home at around 8 pm has dinner and goes to sleep.

FAMILY HISTORY

Father was 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 is consious ,coherent ,cooperative and well oriented to time place and person.He is well built and well nourished.

pallor - absent

icterus  - absent

cyanosis - absent

clubbing - absent     

 lymphadenopathy - absent

edema - absent

VITALS

Pulse rate-60 bpm

Respiratory rate- 18 cpm   

Blood pressure- 130/80mmHg

Temperature- afebrile

On examination of head to foot, there no presence of neurocutaneous markers,congestive cardiac failure.

SYSTEMIC EXAMINATION 

CENTRAL NERVOUS SYSTEM EXAMINATION

Higher mental function-conciousness,oriented to time place and person.
SPEECH - slurring of speech present, no fluency
Memory - Normal,No delusions or hallucinations

CRANIAL NERVE EXAMINATION :-

I- Olfactory nerve-sense of smell is present

II- Optic nerve-direct and indirect light reflex is  present

III- Oculomotor nerve IV- Trochlear nerve and VI- Abducens- direct and consenual light reflex, accomodation reflex are  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-loss of nasolabial fold on right side and mouth deviated to left side.

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 TOWARDS 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

CARDIOVASCULAR SYSTEM EXAMINATION 

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

PALPATION- apical impulse felt at 5 ICS .

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

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

ABDOMEN EXAMINATION 

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

PALPITATIONS -no pain and tenderness no organomegaly

AUSCULTATION -bowel sounds  heard

PROVISIONAL DIAGNOSIS 

Sudden onset ,right sided dense hemiplegia with facial palsy due Acute cerebrovascular accident involving lenticulostriate branch of left mca territory probably due to thrombus and patient has a risk factor of hypertension 

INVESTIGATIONS 

Complete blood picture

 Hemoglobin:11.7mg/dl

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

CAROTID DOPPLER

MRI REPORT 

Infarcts in left internal capsule

TREATMENT 

TAB.CLOPITAB 75mg 

TAB. Ecospirin 75mg