1801006197 - LONG CASE

1801006197- LONG 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 patient came to the opd on 7 days ago with chief complaints of slurring of speech since 9 days(11-03-2023) and deviation of mouth towards the left side since 9 days(11-03-2023).

HISTORY OF PRESENTING ILLNESS 

Patient is apparently asymptomatic 9 days back then he developed slurring of speech and deviation of mouth towards left side and deviation of tongue towards the right side that was noticed by his wife.

He also had history of headache since then.

He also had blurring of vision for about an hour.

He was taken to the local doctors where he was given with some treatment and when symptoms did not subside then he was to our hospital.

He is able to do all his daily activities normally (like getting up from bed, brushing, bathing, combing, wearing clothes, eating, sitting and getting up, wearing footwear , walking).

There is no history of loss of consciousness.

There is no history of trauma.

There is no history of weakness of upper and lower limbs.

There is no history of projectile vomiting.

There is no history of seizures.

There is no change in his behaviour or sensorium.

His daily routine includes:-

My patient wakes up by 5am and does prayer with his wife , then he completes his daily activities, and consumes breakfast mostly rice by 8am and leaves to work with his wife by 9am, then has his lunch by 1pm. After completing his work he reaches home by 6pm gets freshened up has his tea , evening he does prayer with his wife and has dinner mostly rice by 8pm and goes to bed by 9-10pm.

                                             Present

                                            

                                                         Before  

PAST HISTORY 

There are no similar complaints in the past.

History of decreased hearing since 20 years.

History of TB 15 years back , and took medication for 6 months.

He is a known case of hypertension since 1 year , and is under medication but uses them irregularly. 

He is not a known case of diabetes, epilepsy, chest pain and cardiovascular diseases.

TREATMENT HISTORY 

Patient is on medication of atenolol and amlodipine.

PERSONAL HISTORY 

Diet :- mixed

Appetite :- normal 

Sleep :- decreased 

Bowel and bladder movements :- regular 

Addictions :- 20 years back he stopped consuming toddy.

                        now doesn’t have any addictions.

FAMILY HISTORY 

There is history of tb in his family affecting his father , brother and his wife and both of their children.

 His father is a known case of diabetes, hypertension and died of covid.

His both sisters are also known cases of hypertension.

His brother had history of stroke 3 years back.

GENERAL EXAMINATION 

Patient is conscious coherent and cooperative, well oriented to time place and person.

He is moderately built and moderately nourished.

There are no signs of pallor , icterus , cyanosis, clubbing, lymphadenopathy and pedal edema.

 

Vitals

Temperature is afebrile.

Pulse is 66 beats per minute.

Blood pressure is 130/90 mm of hg.

Respiratory rate is 16 cycles per minute.

SYSTEMIC EXAMINATION 

 

CENTRAL NERVOUS SYSTEM 

 

He is conscious coherent and cooperative.

He is able to recognise his family members.

While speaking there is slurring of speech , and repeating the words is seen.

Cranial nerves examination 

1. Olfactory nerve- he is able to perceive smell.

2. Optic nerve- direct and indirect light reflex is present.

3. Occulomotor, 4. Trochlear , 5. Abducens - eye movements are normal , there is no Diplopia , nystagmus or ptosis.

5. Trigeminal - corneal reflex is present;  masseter, temporalis and pterygoid muscles are normal.

7. Facial - face is symmetrical, wrinkling is present, nasolabial folds are seen on both the sides.

8. Vestibulococclear- there is decreased hearing more on the left side , tuning fork test is negative more  on the left side.

9. Glossy pharyngeal- palatal movements are seen.

10. Vagus- palatal movements are seen.

11. Accessory - trapezius and sternocleidomastoid muscle contraction is seen.

12. Hypoglossal - mild deviation of tongue towards right side.

Motor system examination.

BULK                    Right                     Left

Appearance       normal                  normal

Upper limb

   -arm                   28cm                  30cm

  -forearm             26cm                 26cm

Lower limb 

   -thigh                 49cm                49cm

   - leg                    32cm                 31cm

TONE                   Right                    Left

Upper limb          Normal               Normal

Lower limb          Normal               Normal

POWER                Right                  Left

Upper limb

 - shoulder            5/5                       5/5

 -elbow                  5/5                       5/5

 -hand                    5/5                       5/5

Lower limb

 -hip                       5/5                      5/5

 -knee                    5/5                      5/5

 -ankle                   5/5                      5/5

Reflexes

 -biceps                  ++                       ++

 -triceps                 ++                        ++

 -knee                     ++                        ++

 -ankle                    ++                        ++

Superficial reflexes.  

Corneal and abdominal reflexes are normal.

Sensory system examination 

Crude and fine touch- present 

Pain-present

Temperature-present

Tactile localisation -present 

Coordination test

Finger nose test- able to perform.

Heel shin test - able to perform.

Dysdiadochokinesis

Gait is normal.

Meningeal signs.

Neck stiffness, Kernigs, brudzinsky signs are not elicited.

CVS

Inspection:- shape is normal and symmetrical.

                no visible pulsations, dilated veins and scars.

Palpation:- apical impulse is felts at the 5th intercostal space                medial to the mid clavicular line.

Percussion:-left and right heart borders are normal.

Auscultation:- s1 and s2 heard, no murmurs heard .

RESPIRATORY SYSTEM 

 Inspection:- trachea appears to be central.

                        No dilated veins, no scars seen.

Palpation:- trachea is central , chest wall moves symmetrically with respiration, tactile vocal fremitus symmetrical and normal.

Percussion:- resonant, no pain and tenderness.

Auscultation:- bilateral air entry is seen , normal vesicular breath sounds are heard.

PER ABDOMEN 

Inspection:- no visible scars and sinuses, visible peristalsis. umbellicus is normal.

Palpation :- is soft and non tender, no organomegaly.

Auscultation:- bowel sounds are heard.

Provisional diagnosis 

Acute cerebrovascular accident involving left middle cerebral artery region.

Investigations ordered.

Complete blood picture

Complete urine examination 

Fever chart

Carotid Doppler

MRI 

Impression:- infarcts in the left internal capsule.

Final diagnosis

Acute cerebrovascular accident with the infarct in the left internal capsule.

TREATMENT 

Tab. Clopitab 75mg po/od.

Tab.ecosprin av 75/10 po.