1801006088- SHORT CASE

 

1801006088- SHORT CASE 

March 16, 2023   

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 global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan .

CASE:

CHIEF COMPLAINTS:

50 Years old male ,resident of miryalaguda,works in ice factory, came with chief complaints of right sided weakness (upper limb and lower limb) , deviation of mouth to left side and slurring of speech since 2 days (12/3/2023 at 4 am).

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1month back then he developed giddiness and weekness in left lower limb and left upper limb(lowerlimb> upper limb), so he went to the hospital , there he diagnosed with hypertension,they gave antihypertensives (amlodipine and atenolol).his left sided weakness was resolved in 3 days.he took the antihypertensives for 20 days and after that he stopped medications since 10 days onwards because his friends told that take alcohol it will resolves the weakness of limbs. So he stopped medications and took the alcohol since 10 days.on 11/3/2023 night also he took alcohol and slept , on 12/3/2023 at 4am he woke up but he developed giddiness, unable to stand  due to weekness in the right upper and lower limbs, deviation of mouth to left side and slurring of speech. So he was taken to the miryalaguda hospital there he underwent CT scan then they referred to our hospital.he came to our hospital on 13/3/2023.

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

                                       

                                            

DAILY ROUTINE:

Daily he wake up at 4:00am does his morning routine and drinks tea and goes to work ,at 9 '0 clock he comes to home and have breakfast and goes to work till  2 pm and will have his lunch at home ,he then again goes to work till 9pm returns home will have his dinner and sleeps at 10pm.

PAST HISTORY:

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

He is a known case of hypertension since 1 month.

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

PERSONAL HISTORY: 

                 

                          

Diet- mixed

Appetite - normal

Sleep -normal

Bowel and bladder -regular

Addictions-

-He is chronic alcoholic since 30 years, stopped 3 years back but again started 6 mns back after death of  his daughter's husband.

-he chews tobacco since 10 years (1 packet per 2 days). 

FAMILY HISTORY:

No similar complaints in the family.

TREATMENT HISTORY:

He is on Antihypertensives (amlodipine and atenolol) since 1mn 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.

Vitals :- 

Temp - afebrile

BP  - 140/80 mm Hg

Pulse rate - 78 bpm

Respiratory rate - 14 cycles per minute 

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent

                                     

                                           

                                                  

                                              

SYSTEMIC EXAMINATION:

1) 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: 

Superficial reflexes:

                          Right               Left

Corneal :         present          present

Conjunctival:  present          present

Abdominal:     present  in all quadrants

Plantar :          not elicited     flexion

Deep tendon reflexes:

                            Right                 Left

Biceps                  ++                     ++

Triceps                 ++                     ++

Supinator             ++                     ++

Knee jerk             +++                   ++

Ankle jerk            +++                   ++

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

 

 

RESPIRATORY SYSTEM 

Inspection:   

Shape of the chest : elliptical 

B/L symmetrical , 

Both sides moving equally with respiration 

No scars, sinuses, engorged veins, pulsations

Palpation:

Trachea - central

Expansion of chest is equal on both side

Tactile vocal fremitus Normal

Auscultation:

 . Normal vesicular breath sounds sounds heard

CARDIOVASCULAR SYSTEM

Inspection :

Shape of chest- elliptical shaped chest.

No engorged veins, scars, visible pulsations 

JVP is not raised

Palpation :

 Apex beat can be palpable in 5th inter costal space medial to mid clavicular line

No thrills and parasternal heaves can be felt

Auscultation :

S1,S2 are heard

no murmurs 

ABDOMEN EXAMINATION:

Inspection -

Umbilicus - inverted

All quadrants moving equally with respiration

No scars, sinuses and engorged veins , visible

 pulsations.

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion - liver dullness is heard at 5th intercoastal space

Auscultation- normal bowel sounds heard.

PROVISIONAL DIAGNOSIS:

Right hemiparesis due to cerebrovascular accident probably involving internal capsule.

INVESTIGATIONS :

Anti HCV antibodies rapid - non reactive 

HIV 1/2 rapid test - non reactive

Blood sugar random - 109 mg/dl 

FASTING BLOOD SUGAR- 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

COMPLETE URINE EXAMINATION:

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

LIVER FUNCTION TESTS:

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

THYROID FUNCTION TESTS: 

T3 - 0.75 ng/ml 

T4 - 8 mcg/dl 

TSH - 2.18 mIU/ml

 

ECG

                

MRI

                             

                                        

                                            

                                    

                                            

Impression:  

Acute infarct in posterior limb of left internal capsule

Old lacunar infarct in left side of pons

Few microhemorrhages in bilateral cerebral hemispheres.

CONFIRMED DIAGNOSIS:

Cerebrovascular accident with Right sided hemiparesis ,

Acute infarct in posterior limb of internal capsule.

TREATMENT:-

Tab. ECOSPRIN

 

Tab. CLOPITAB

 

Tab. ATOROVAS

 

Tab. STAMLO BETA

 

Physiotherapy