1801006074- 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 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 comments on 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. 

Chief complaints:

             A 50 year old male, resident of Nalgonda ,who works in an ice factory came with complaints of:

            - weakness of right upper and lower                     limbs since 5 days

            - slurred speech since 5 days.

History of presenting illness:

              Patient was apparently asymptomatic 1 month back, then he developed weakness in left upper and lower limbs which was sudden in onset and was taken to local hospital when he was diagnosed to have hypertension and his condition improved with medication in about 3 days.

             He took medication for 20 days and stopped for next 10 days when he developed sudden onset of weakness in right upper and lower limbs (which was 5 days ago). He also developed slurred speech and was taken to local hospital and then was referred to our hospital next day.

             There is no history of loss of consciousness, altered sensorium,fever,headache,vomiting,seizures,behavioural abnormalities or abnormal movements.

 

Past history:

He is a known case of hypertension since 1 month.

There is no history of diabetes, asthma,TB,epilepsy,coronary artery disease or thyroid abnormalities.

Personal history:

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 takes mixed- diet.He finishes work by around 6:00 pm, comes home, has tea and takes a bath. Sometimes he works until 9:00 pm. He sleeps by 9:00 pm. 

The patient has history of chewing tobacco for around 10 years.

He consumes alcohol regulary since 30 years. He stopped for around 3 years and started again 6 months ago.

Bowel and bladder movements-regular.

Treatment history:

He took medication for hypertension- Amlodipine and Atenolol for 20 days and stopped for the past 15 days.

Family history:

No history of similar complaints in the family.

General examination:

Patient is conscious and cooperative. 

He is well oriented to time,place and person.

Moderately built and 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:

CNS EXAMINATION:

Right handed person.

Higher mental functions are intact.

Speech- slurred

Behaviour-normal

Memory- intact

Intelligence-normal

No hallucinations or delusions

Gait:

CRANIAL NERVE EXAMINATION:

I - no alteration in smell

II -

Visual acuity- normal

Field of vision- normal 

Color vision - normal

III, IV, VI -

EOM- normal

Diplopia- absent

Nystagmus absent

No ptosis

V - sensations of face normal, can chew food normally 

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

Taste sensation over anterior 2/3 of tongue present

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

Pupils - both are normal in size, reactive to light 

Motor examination:

Tone:

RUL: increased

LUL: normal

RLL: increased

LLL: normal

Power:

RUL: 3/5

LUL: 4/5

RLL: 3/5

LLL: 4/5

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 examination:

Pain, temperature, crude touch, pressure sensations- normal

Fine touch, vibration, proprioception- normal

No abnormal sensory symptoms .

Tactile localisation- able to localise

Cerebellar examination:

Finger nose test- normal

No dysdiadochokinesia

Knee heel test - 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

3) 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, rub or venous hum

4) RESPIRATORY EXAMINATION :- 

- Chest bilaterally symmetrical, all quadrants

moves equally with respiration.

- Trachea central, chest expansion normal.

- Resonant on percussion

- Bilateral equal air entry, no added sounds heard.

1. Breath sounds -  Normal Vesicular Breath sounds

2. Added sounds - absent

3.  Vocal Resonance - normal

4. Bronchophony, Egophony, Whispering Pectoriloquy absent

PROVISIONAL DIAGNOSIS:

Right hemiparesis due to cerebrovascular accident.

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

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.

USG: 

No sonological abnormalities detected.

ECG:

               Regular Rhythm,60 bpm

TREATMENT:-

Tab.ECOSPRIN 

Tab.CLOPITAB 75mg PO/OD 

Tab.Stamlo beta

Physiotherapy of right upper limb and lower limb