S.Vikas Varma 1701006154 long case

1701006154LONG CASE

March 15, 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 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. 

CASE

This is a case of a 50 year old male with the chief complaints of - 

Weakness of right upper and lower limbs with slurring of speech and deviation of mouth since 2 days



HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic 30 years ago. He then sustained a fracture close to his right elbow. He currently cannot extended his elbow completely.

1 month ago he developed giddiness and weakness of left upper and lower limbs which was sudden in onset followed by fall. He was then taken to the hospital where he was treated for the same and diagnosed with hypertension. His symptoms resolved in around 3 days. The patient was complaint with his hypertension medication for 20 days and stopped taking it after that. 

The patient then developed weakness of right upper limb and lower limb which was sudden in onset. He noticed the weakness on his right side when he woke up in the morning. He felt unsteady as he stood up after waking up. 

The weakness of right side was also associated with slurring of speech and deviation of the mouth to his left side. He was taken to a hospital nearby where he underwent a CT scan. He was then referred to our hospital the next day.

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


PAST HISTORY:-

He is known case of hypertension from past 1 month

No history of diabetes, asthma, TB, epilepsy, coronary artery disease, or any thyroid abnormalities.


PERSONAL HISTORY:- 

The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days. 

He consumes alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago after the death of his daughter’s husband.

Bowel and bladder movements are regular.


TREATMENT HISTORY:- 

He consumed medication for hypertension - Amlodipine and Atenolol for 20 days which he stopped around 10 days ago.


FAMILY HISTORY:- 

No similar complaints in the family.


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 
















SYSTEMATIC EXAMINATION:-


1) CNS EXAMINATION :- 

No meningeal signs like neck stiffness and Kernigs sign

Glasgow scale - 15/15

Gait - walks only with support 

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 right side and left 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

Pupils - both are normal in size, reactive to light





 



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: 

                   Right                    Left

Biceps.                      

                +++                    +++

Triceps.                      

                     +++                    +++

Supinator.                 

                     +++                    +++

Knee.                          

                     +++                    +++

Ankle.                          

                     +++                    +++

Plantar:                  

                      Muted             Flexion



Involuntary movements - absent


Fasciculations - absent


Sensory system - 

Pain, temperature, crude touch, pressure sensations normal

Fine touch, vibration, proprioception normal

No abnormal sensory symptoms 


Cerebellum - 

Finger nose test normal, no dysdiadochokinesia, Rhomberg test could not be done


Autonomic nervous system - normal 


2) 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



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 BRAIN:


ACUTE INFARCT IN POSTERIOR LIMB OF LEFT INTERNAL CAPSULE

OLD LACUNAR INFARCT IN LEFT SIDE OF PONS

FEW MICROHEMORRHAGES IN BILATERAL CEREBRAL HEMISPHERES

MR ANGIOGRAM NORMAL


CT Scan



ECG






PROVISIONAL DIAGNOSIS:- 

Cerebrovascular accident with Right Hemiparesis due to involvement of internal capsule posterior limb


TREATMENT:-

Inj. OPTINEURON in NS 100 ml
Tab. ECOSPRIN
Tab. CLOPITAB
Tab. ATOROVAS
Tab. STAMLO BETA
Physiotherapy


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