Final practical medicine long case

This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs 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 diagnosis and treatment plan.


Registration no.1701006174

Case: 
A 65 year old male patient came to the opd with chief complaints of right sided weakness, deviation of mouth and drooling of saliva

History of present illness:

Patient was apparently asymptomatic 10days back then he developed weakness in right upper limb and lower limb, deviation of mouth, slurred speech and  drooling of Saliva from mouth which is sudden in onset, progressive in nature .
It is not associated with difficulty in breathing, difficulty in lifting head off the pillow.
There is no history of trauma,headache, vomiting, diarrhoea,chest pain,calftenderness.

Pasthistory:
History of similar complaints in the past.


Patient is a known case of hypertension on medication.
Not a known case of DM, epilepsy,asthma.

Personal history:
Diet: stopped non veg 5years back
Appetite: normal
Bowel and bladder movements: normal
No significant weight loss
Occasional drinker
No allergies

Family history:not significant


General examination:

Patient is examined with an informed consent and well illuminated room
patient is well oriented to time but not to place and person 
Moderately built and nourished 
No pallor,icterus,cyanosis, clubbing,cyanosis lymphadenopathy, edema

Vitals:
Temperature:Afebrile 
PR:70bpm
RR:16cpm
BP:140/80mm of hg










     Systemic examination ;

CVS: s1 s2 heard 
        No murmurs 
Respiratory system; normal vesicular breath sounds are heard 
Abdomen: soft non tender no organomegly

CNS;
Higher functions:
Right handed 
Conscious 
Oriented to time not place and person 
Memory: recent- present 
              Immediate: present 
              Remote: absent 
Speech:
            Not spontaneous 
            comprehension- present 
            Naming- absent 
            Repetition- absent 
            Disarticulation of speech - present 
No delusions or hallucinations 
Cranial nerve examination:
I- Olfactory nerve- sense of smell present 
II- Optic nerve- direct and indirect light reflex present.
III-Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis
V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.
VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.
VIII- Vestibulocochlear nerve- no hearing loss
IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised
XI- Accessory nerve- sternocleidomastoid contraction present
XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue
 

Spinomotor system:

                            Right        Left  
BULK: U/L- arm 24.5 cm 26 cm                                  
                 -forearm 18 cm 18 cm   
                                      
                  L/L- thigh 44 cm 44 cm
                           - leg 28 cm 28 cm
                  
TONE:          U/L decreased normal
                       L/L decreased normal
                          
4c) Sensory system examination:

                           Right      Left  
crudetouch:.   Absent present
fine touch    : absent present          
pain                absent present
vibration         absent present
temperature  absent present
stereognosis- absent present 
2 pt discrimination- absent present
graphaesthesia- absent present 


                            Right     Left 
POWER: U/L- hand 0/5 5/5
                            - elbow 0/5 4/5
                            - shoulder 0/5 5/5

                    L/L- hip 0/5 4/5
                           - knee 0/5 5/5   
                            - ankle 0/5 4/5

REFLEXES: Biceps +++ ++
                        Triceps +++ ++
                    Supinator +++ ++
                          Knee +++ ++
                        Ankle +++ ++
                          Plantar extension neutral

Reflexes of right upper limb and lower limb: 


Tone of right upper limb and lower limb:
Babinski sign:




Investigation 
CBP
Hemoglobin- 12.6 gm/dl (N)
PCV- 35.2 % (N)
TLC- 8600/ cumm (N)
RBC- 4.33 million/cumm (N)
Platelets- 2.58 lakhs/ml (N)
Blood urea- 24 mg/dl (N)
Serum creatinine- 1.3 mg/dl (N)
Serum sodium- 136 mEq/L  (N)
Serum potassium- 3.7 mmol/l (N)
Serum chloride- 104 mEq/L (N)
LFT
Total bilirubin- 0.61 mg/dl  (N)
Direct bilirubin-  0.16 mg/dl (N)
SGPT- 11 (N)
SGOT- 13 (N)
ALP- 105 IU/L (N)Albumin- 4 g/dl (N)

ECG


MRI
2017:

2022



PROVISIONAL DIAGNOSIS:
Acute ischemic stroke causing right sided hemiplegia (left MCA territory)
Recurrent CVA 

TREATMENT:
Tab. Ecosporine 150mg
Tab. Clopidogrel 75 mg
Tab. Atorvas 40mg
Tab. Atenolol 25mg
Physiotherapy




























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