1801006148 - LONG CASE

 This is an 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.


CASE


This is a case of a 50 year old male,  resident of Miryalguda, factory worker by occupation, presented with 


CHEIF COMPLAINTS- 

Weakness of right upper and lower limbs with slurring of speech and deviation of mouth to the left since 3 days


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 month ago, then he developed giddiness and weakness of left upper and left lower limb which was sudden in onset followed by fall. He was then taken to the hospital where he was treated for the same and diagnosed with hypertension. His symptoms resolved in around 3 days. The patient was compliant with his hypertension medication for 20 days and stopped taking it after that. 

The patient then developed weakness of right upper limb and lower limb 3 days ago(lower limb>upper limb) which was sudden in onset. He noticed the weakness on his right side when he woke up in the morning. He felt unsteady as he stood up after waking up. 

The weakness of right side was also associated with slurring of speech and deviation of the mouth to his left side. He was taken to a hospital nearby where he underwent a CT scan. He was then referred to our hospital the next day.

There is no history of difficulty in swallowing, behavioural abnormalities, fainting, sensory disturbances, fever, neck stiffness, altered sensorium, headache, vomiting, seizures, abnormal movements, falls.



PAST HISTORY:

Fracture near the right elbow due to fall from the tree 30 years ago ,so he cannot extending his right hand completly.

He is a known case of hypertension since 1 month .

Not a k/c/o Diabetes,asthma, coronary artery diseases,epilepsy,thyroid disorders.



FAMILY HISTORY:

No similar complaints in the family



PERSONEL HISTORY:

( daily routine )

The patient wakes up at 4:00am in the morning daily. He has tea and goes to work in the ice factory. He lives very close to the ice factory. He comes home and has breakfast at around 8 to 9 am. He usually has rice and curry for breakfast. He then goes back to work and comes home for lunch at around 2:00 pm. He usually has rice with curry and dal for lunch. He consumes chicken or mutton thrice weekly. He sometimes takes a nap in the afternoon depending on his work for the day. He finishes work by around 6:00 pm following which he comes home, has tea and takes a bath. Sometimes he works until 9:00 pm. He sleeps by 9:00 pm. 

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.

Bowel and bladder movements are regular.



TREATMENT HISTORY:

He is on antihypertensives (amlodipine and atenolol) since 1month but 10 days onwards he stopped medications.



GENERAL EXAMINATION:

Patient is conscious, cooperative, with slurred speech 

Well oriented to time, place and person

Moderately built and moderately nourished.













Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 


Vitals :- 

Temp - afebrile

BP - 140/80 mm Hg

Pulse rate - 78 bpm

Respiratory rate - 14 cycles per minute 


SYSTEMIC EXAMINATION:


CNS EXAMINATION:

Dominance - Right handed

Higher mental functions

 • conscious

 • oriented to time,person and place

 • memory - immediate,recent,remote intact

 •slurring of speech




Cranial nerves - 


I - no alteration in smell

II - no visual disturbances

III, IV, VI - eyes move in all directions

V - sensations of face normal, can chew food normally 

VII - Deviation of mouth to the left side, upper half of left side and right side normal

VIII - hearing is normal, no vertigo or nystagmus 

IX,X - no difficulty in swallowing 

XI - neck can move in all directions 

XII - tongue movements normal, no deviation


Power:-


Rt UL - 3/5 Lt UL-5/5


Rt LL - 3/5 Lt LL-5/5


Tone:-


Rt UL - Increased


Lt UL- Normal


Rt LL- Increased


Lt LL- Normal









Reflexes: 


                   Right             Left


Biceps: +++                    ++


Triceps: +++                  ++


Supinator: +++              ++


Knee: +++                      ++


Ankle: +++                     ++



Plantar: Muted             Flexion


Involuntary movements - absent


Fasciculations - absent



Sensory system - 

-Pain, temperature, crude touch, pressure sensations normal

-Fine touch, vibration, proprioception normal

-two point discrimination -able to discriminate and tactile localisation -able to localise


Cerebellum - 

Finger nose test normal, no dysdiadochokinesia, Rhomberg test could not be done

Autonomous nervous system - normal




CVS EXAMINATION:

JVP: Normal


INSPECTION:

Chest wall symmetrical

Pulsations not seen


 PALPATION:

Apical impulse – normal

Pulsations – normal

Thrills absent


 PERCUSSION:

No abnormal findings

 

AUSCULTATION: 

S1, S2 heard

No murmurs 

No added sounds


ABDOMINAL EXAMINATION :- 

INSPECTION:

1. Shape – flat

2. Flanks – free

3. Umbilicus – Position-central, Shape-normal

4. Skin – normal

5. Hernial Orifices - normal 


 PALPATION:

Abdomen is soft and non tender

No hepatomegaly

No splenomegaly 

Kidneys not enlarged, no renal angle tenderness

No other palpable swellings

Hernial orifices normal


PERCUSSION:

Fluid Thrill/Shifting dullness/Puddle’s sign absent


AUSCULTATION:

Bowel sounds – normal 

No bruits.



RESPIRATORY EXAMINATION :- 


Inspection: 

Shape- elliptical 

B/L symmetrical , 

Both sides moving equally with respiration .

No scars, sinuses, engorged veins, pulsations 


Palpation:

Trachea - central

Expansion of chest is symmetrical. 

Vocal fremitus - normal

Percussion: resonant bilaterally 


Auscultation:

 bilateral air entry present. Normal vesicular breath sounds heard.



PROVISIONAL DIAGNOSIS:

Acute Cerebrovascular accident with Right Hemiparesis due to involvement of internal capsule posterior limb



INVESTIGATIONS 

Anti HCV antibodies rapid - non reactive 


HIV 1/2 rapid test - non reactive


Blood sugar random - 109 mg/dl 

FBS - 114 mg/dl


Hemoglobin- 13.4 gm/dl

WBC-7,800 cells/cu mm

Neutrophils- 70%

Lymphocytes- 21%

Eosinophils- 01%

Monocytes- 8%

Basophils- 0

PCV- 40 vol%

MCV- 89.9 fl 

MCH- 30.1 pg

MCHC- 33.5%

RBC count- 4.45 millions/cumm

Platelet counts- 3.01 lakhs/ cu mm


SMEAR:


RBC - normocytic normochromic

WBC - with in normal limits

Platelets - Adequate

Haemoparasites - no 


CUE:


Colour - pale yellow

Appearance- clear 

Reaction - acidic

Sp.gravity - 1.010

Albumin - trace

Sugar - nil

Bile salts - nil

Bile pigments - nil

Pus cells - 3-4 /HPF

Epithelial cells - 2-3/HPF

RBC s - nil 

Crystals - nil

Casts - nil 

Amorphous deposits - absent


LFTs:


Total bilirubin - 1.71 mg/dl

Direct bilirubin- 0.48 mg/dl

AST - 15 IU/L

ALT - 14 IU/L

Alkaline phosphatase - 149 IU/L

Total proteins - 6.3 g/dl

Albumin - 3.6 g/dl

A/G ratio - 1.36

Blood urea - 19 mg/dl

Serum creatinine - 1.1 mg/dl

Electrolytes 

Sodium - 141 mEq/L

Potassium - 3.7 mEq/L

Chloride - 104 mEq/L

Calcium ionised - 1.02 mmol/L

T3 - 0.75 ng/ml 

T4 - 8 mcg/dl 

TSH - 2.18 mIU/ml


ECG




CT scan




MRI scan









CONFIRMED DIAGNOSIS:

Left sides Cerebrovascular accident with Right sided hemiparesis ,

Acute infarct in posterior limb of internal capsule.


TREATMENT:

Inj. OPTINEURON in NS 100 ml

Tab. ECOSPRIN

Tab. CLOPITAB

Tab. ATOROVASTAT

Tab. STAMLO BETA

Physiotherapy






17/03/23:

S:
Stools paased 

O:
O/e
Patient is c/c/c
BP: 140/90mm hg
Pr: 84bpm
Rr: 17cpm
Cvs: s1 and s2 present. No murmurs
Rs: b/l air entry present. NVBS 
P/a soft non tender
CNS: 
                    Right. Left
Tone:. Ul. Increased . Increased 
            Ll. Hyper. Increased 
Power: Ul. 4/5. 5/5
              Ll. 4/5 5/5

Reflexes :
          
Right:      
Biceps: 3+
Triceps: 3+
Supinator: 2+
Knee: 3+
Ankle: 2+
Plantar: extensor 
Left:
Biceps: 3+
Triceps: 3+
Supinator: 3+
Knee: 3+
Ankle: 3+
Plantar: flexor
Bilateral pupils: Nirmal size reacting to light

A:
CEREBROVASCULAR ACCIDENT WITH RIGHT HEMIPARESIS WITH ACUTE INFARCT IN POSTERIOR LIMB OF LEFT INTERNAL CAPSULE
K/C/O HTN SINCE 1 MONTH

P:
1. INJ. OPTINEURON 1 AMP IN 100ML NS IV/OD
2. TAB. ECOSPRIN AV 75/10 PO/HS
3. TAB. CLOPITAB 75 MG PO/OD
4. PHYSIOTHERAPY OF RIGHT UPPER AND LOWER LIMB
5. VITALS MONITORING
6. SYRUP. CREMAFFIN PLUS 15ML PO/HS
7. I/O CHARTING


18/03/23


S:

Stools passed 


O:

O/e

Patient is c/c/c

BP: 150/90mm hg

Pr: 84bpm

Rr: 18cpm

GRBS:108mg/dl

Cvs: s1 and s2 present. No murmurs

Rs: b/l air entry present. NVBS 

P/a soft non tender

CNS: 

 Tone: R. L

UL increased increased

LL. N. Increased

POWER: R. L

UL 4/5. 5/5

LL. 4/5. 5/5

REFLEXES: R. L

biceps. 3+. 3+

Triceps. 3+. 3+

Supinator. 2+. 3+

Knee. 3+. 3+

Ankle. 2+. 3+

Plantar. Extension flexion



A:

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

K/C/O HTN SINCE 1 MONTH


P:

1. INJ. OPTINEURON 1 AMP IN 100ML NS IV/OD

2. TAB. ECOSPRIN AV 75/10 PO/HS

3. TAB. CLOPITAB 75 MG PO/OD

4. PHYSIOTHERAPY OF RIGHT UPPER AND LOWER LIMB

5. SYRUP. CREMAFFIN PLUS 15ML PO/HS

Comments

Popular posts from this blog

Medicine internship

OSCE

65 yr old female with chief complaints of diarrhoea, vomitings , and generalised weakness since 5 days