1801006191 - Short case
1801006191 - Short case
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.
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS
A 50 year old male , ice factory worker by occupation, from Mirualguda presented to the casualty with weakness of right upper and lower limbs with slurring of speech and deviation of mouth to the left side since the morning of 13/3/23 4am.
History of presenting illness :
Patient was apparently asymptomatic 1 month back, he then developed giddiness followed by a fall. He was taken to the hospital and was diagnosed with hypertension for which he used medication only for 20 days and then was non compliant after that .
The patient then developed sudden onset of weakness in his right upper and lower limbs that was associated with deviation of the mouth to left side and slurring of speech.
There is no complaint of unconsciousness, difficulty in swallowing, sensory disturbances, headaches, nausea, vomiting, seizure episodes , no bladder or bowel incontinence .
There is no complaint of neck rigidity.
Past history :
History of trauma to the right elbow due to a 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 who was compliant to medication only for 20 days .
Not a known case of diabetes, coronary artery diseases, epilepsy .
Family history : No similar complaints in the family
Personal history :
Daily routine of the patient :
The patient wakes up at 4:30am in the morning has tea and goes to work in the ice factory. He lives in quarters given in the factory itself. He comes back home around 1 pm to have his lunch which is usually rice, curry and dal. He consumes chicken or mutton thrice weekly. He sometimes takes a nap in the afternoon depending on his work for the day. He finishes his work by 6:00 pm following which he comes home, has his dinner and sleeps by 8:30 pm.
The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days.
He consumed 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 was on Amlodipine and Atenolol for only 20 days .
General Examination :
Patient is conscious, coherent, cooperative, well oriented to time, place and person, moderately built and nourished .
Pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy and pedal edema are absent.
VITALS :
Temperature : afebrile
Blood pressure : 140/80 mm Hg
Pulse rate : 86 bpm
Respiratory rate : 18 cpm
Systemic Examination :
Central nervous system examination :
Higher mental functions :
• conscious
• oriented to time, person and place
• memory - immediate,recent,remote intact
•slurring of speech present
Cranial nerves :
I - can smell normally
II - no visual disturbances
III, IV, VI - Able to move eyes in all directions - Direct and indirect light reflexes are present
- Accomodation reflex present .
V - Sensations of face are normal
- Can chew food normally
- Corneal and conjunctival reflexes are present
- Jaw jerk present
VII - Deviation of angle of mouth to the left side
- Presence of wrinkling on the right forehead when asked to frown
- Taste sensation is normal in the anterior two thirds of tongue
VIII - Hearing is normal
- No vertigo or nystagmus
IX , X - Pharyngeal reflex is present
XI - Able to shrug his shoulders on both sides against resistance
XII - tongue movements normal, no deviation or fasciculations
Motor :
BULK - there is no wasting or atrophy of the muscles
POWER
Right. Left
Upper limb. 4/5. 5/5
Lower limb. 4/5. 5/5
TONE
Right. Left
Upper limb. Hypertonia. Normal
Lower limb. Hypertonia. Normal
REFLEXES
Right. Left
Biceps. +3. +2
Triceps. +3. +2
Supinator. +3. +2
Knee. +3. +2
Ankle. +3. +2
Babinski's sign Positive. Negative
( Abnormal ). ( Normal )
Sensory :
- Pain, temperature, crude touch are normal
- Fine touch, vibration, proprioception are normal
- Two point discrimination - able to discriminate
- Tactile localisation - able to localise
Cerebellar signs :
- Vertigo - absent
- Nystagmus - absent
- Intention tremors - absent
- Slurred speech - present
- Hypotonia - absent
- Dysdiadochokinesia - absent
Signs of meningeal irritation :
- Neck stiffness, Brudzinski's sign, Kernig's sign are absent
Cardiovascular system examination :
On inspection :
. The chest wall is bilaterally symmetrical, there are no skeletal deformities.
. There are no dilated and engorged superficial veins .
. Apical pulsation present, there are no other pulsations .
On palpation :
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line.
• JVP was normal
• No parasternal heave
On auscultation ‐ S1, S2 heard , no murmurs
Respiratory system examination :
On inspection :
- The chest is bilaterally symmetrical .
- Both sides of chest are moving equally with respiration .
- There are no dilated and engorged superficial veins .
On palpation :
- Expansion of chest is symmetrical .
- Position of trachea is central .
- Tactile vocal fremitus - normal
On percussion - resonant note heard on both sides of the chest .
On auscultation - bilateral air entry present, normal vesicular breath sounds are heard, vocal resonance is normal .
Abdominal examination : soft, non tender, no organomegaly, bowel sounds heard .
Provisional diagnosis : Cerebrovascular accident with right sided hemiparesis
Investigations :
Fever chart
Anti HCV antibodies - non reactive
HIV 1/2 rapid test - non reactive
Blood sugar random - 109 mg/dl
FBS - 114 mg/dl
Hemogram :
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
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
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
Final diagnosis : Cerebrovascular accident with right sided hemiparesis. Acute infarct in the posterior limb of internal capsule .
Treatment :
- Tablet Ecosprin 75 mg PO
- Tablet Clopitab 75 mg PO OD
- Syrup Cremaffin plus 15 ml PO
- Physiotherapy of the right upper and lower limb
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