1801006184-LONG CASE
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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 50 year old man resident of Miryalguda, worker in an ice factory and came with chief complaints of weakness of right upper limb and lower limb , slurring of speech and deviation of mouth to left side
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 1 month back then he developed giddiness for which he went to the local hospital and he was also diagnosed to be hypertensive for which he took medication for 20 days(Atenolol and Amlodipine) and stopped since 10 days.
On 13/03/2023 at morning 4 am he developed weakness of right upper limb and lower limb .He also developed slurring of speech and deviation of mouth towards left. He was taken to local hospital and was referred to our hospital.
No history of vomiting headache, unconsciousness,seizures,neck rigidity,valvular heart diseases
PAST HISTORY:
Patient has history of fracture to right elbow 30 years ago.
Known case of hypertension since 1month
No history of diabetes, tuberculosis, epilepsy
No history of trauma to head.
No history of surgeries.
PERSONAL HISTORY:
Diet: Mixed
Appetite: Normal
Sleep: Adequate
Bowel and bladder: Regular
Addictions: Alcoholic since 30 yrs and chews tobacco (Gutka) for 10 years (one packet of gukta lasts for 2days)
DAILY ROUTINE :
Before illness:
4am- gets ready(has tea)and go for work
9am- have breakfast(rice, curry) and go back to work.
1pm- have lunch (rice dal ,curry ,chicken weekly thrice)and go back to work
9 pm- have dinner
10pm- sleeps
After the illness:
He went for work for 20 days and then stopped doing the work.His strength to do work has decreased.
FAMILY HISTORY:
No significant family history
GENERAL EXAMINATION:
Patient was examined in a well lit room after taking informed consent. He is conscious, coherent and cooperative; moderately built and nourished.
Pallor- Absent
Icterus- Absent
Cyanosis- Absent
Clubbing- Absent
Generalised lymphadenopathy- Absent
Edema- Absent
Vitals
1. Temperature- Afebrile
2. Pulse pressure- 75 beats per min
3. Blood pressure- 130/70 mm Hg
4. Respiratory rate- 17 cycles per min
5. GRBS-109mg/dl
SYSTEMIC EXAMINATION:
CENTRAL NERVOUS SYSTEM-
Dominance -Right handed
Higher mental functions-
Conscious
Oriented to time place and person
Memory- Immediate, recent and remote
Slurring of speech present
Cranial nerve examination:
I- Olfactory nerve- sense of smell Normal
II- Optic nerve-
Visual acuity
Field of vision. Normal
Colour vision normal
III, IV, VI. Right Left .
EOM Normal Normal
Diplopia. Absent Absent
Nystagmus Absent Absent
Ptosis Absent Absent
Direct and indirect
Light reflex present
V- Masseter, temporalis and pterygoid muscles are normal on both sides(sensations of face are normal can chew food normally)
VII- - Deviation of mouth to left side
VIII- no hearing loss ,no vertigo
IX- no difficulty in swallowing
X- No difficulty in swallowing
XI -sternocleidomastoid contraction present,
Trapezius- shrugging of shoulders against resistance present
Neck can move in all directions
XII - No deviation of tongue,tongue movements normal
Motor system
Tone Right. Left
Upper limb Increased. Normal
Lower limb Increased Normal
power. Right. Left
Upper limb 3/5 4/5
Lower limb 3/5 4/5
Superficial reflxes
Corneal reflex normal on both sides
Abdominal reflex absent
Right. Left
Plantar. Muted. Flexion
Positive. Negative
Deep tendon reflexes Right Left
Biceps +++ ++
Triceps. +++ ++
Supinator +++ ++
Knee. Jerk +++ ++
Ankle jerk +++ ++
Sensory system
Spinothalamic Rt. Lft
Crude touch + +.
Pain + +
Temperature + +
Posterior column
Fine touch + +
Vibration Normal
Cortical
Two point discrimination- able to discriminate
Tactile localization -able to localise
Cerebellar Examination
Finger nose test-Normal
Heel shin test -Normal
No Dysdiadochokinesia
No meningeal signs
Examination of spine-Normal
Deep tendon reflexes Right side
Biceps:
Triceps:
Knee jerk:
Ankle jerk:
Plantar reflex:
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 heard
CARDIOVASCULAR SYSTEM
Inspection-
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
JVP is not raised
Palpation-
Apex beat in 5th inter costal space medial to mid clavicular line
No thrills and parasternal heaves felt
Auscultation-
S1,S2 are heard
no murmurs heard
ABDOMINAL EXAMINATION
Inspection-
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible. pulsations.
Hernial orifices- free.
Palpation-
soft, non-tender
No palpable spleen and liver
Percussion- Resonant note heard
Auscultation- Normal bowel sounds heard
Provisional diagnosis: cerebrovascular accident with right sided hemiparesis
INVESTIGATIONS
Anti HCV antibodies rapid - non reactive
HIV 1/2 rapid test - non reactive
Random Blood sugar - 109 mg/dl
Fasting blood sugar - 114 mg/dl
Hemoglobin- 13.4 gm/dl
WBC-7,800 cells/mm3
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/mm3
Platelet counts- 3.01 lakhs/ cu mm
Peripheral Smear
RBC - normocytic normochromic
WBC - with in normal limits
Platelets - Adequate
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
MRI
Tab.ECOSPRIN
Tab.CLOPITAB
Tab.ATOROVASTAT
Physiotherapy of right upper limb and lower limb
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