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1801006094 - LONG CASE

 This is an a online e log book to discuss our patient's de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.


This E blog also reflects my patient centred online learning portfolio and your valuable inputs on the comment box is welcome.


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.


3 January 2022

A 55yr old male came with the chief complaints of

*Tingling and Burning sensation in left leg and left hand since 15 days

*Chest pain since 6days 


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6yrs ago then he had an episode of sudden loss of consciousness associated with excessive sweating, which was associated with slurring of speech,  deviation of mouth towards right.

He was taken to hospital in karimnagar and diagnosed with left hemiparesis and is under medication (anti platelets) till date.

He now  presents with the complaint of burning sensation in the left upper  and lower limb since 15 days which is persistent throughout day.

He also complains of  right sided chest pain which is sudden onset ,dragging type , non radiating, intermittent in nature not associated with shortness of breath ,sweating .

Patient complaints of generalized  weakness since 1 year

No history of any other episodes of loss of consciousness, seizures,headache , nausea,vomitings .


PAST HISTORY

Patient had a history of trauma to head 20 years ago( was beaten up by thieves)

For which suture were done and medications were taken

Not a known case of DM,HTN,Epilepsy,Asthma and coronary artery disease.

H/o Right eye cataract surgery 1 year ago .




DAILY ROUTINE

He daily wakes up at 5am ,does his daily routine walk with stick and eats breakfast at 8 am.Then he watches tv and have lunch at 1 pm sleeps for about 2hrs and the go for walk with stick and have dinner at 8:00 PM and sleep at 10:00 PM.


PERSONAL HISTORY:

Diet: Mixed 
Appetite: decreased since 2 months
Bowel - hard stools once in 2 months
Bladder- burning micturation since 2 months
Sleep:Adequate 
Addictions- Smoking since 40yrs ( one bidi packet per day)
Occassionally alcoholic since 30yrs.


FAMILY HISTORY:

H/0 hemiparesis in grand father and father.


DRUG HISTORY:
No significant drug history.


GENERAL EXAMINATION:

Patient is conscious and co-operative.well oriented to time,place and person.
Moderately build and moderately nourished.


No pallor, icterus, cyanosis,clubbing, lymphadenopathy ,edema


VITALS

TEMPARATURE:Afebrile

BP:140/90 bpm 

PULSE RATE:80/min regular normal volume

RESPIRATORY RATE:16 cycles/min

Spo2 : 95%RA


CENTRAL NERVOUS SYSTEM:

Conscious and  coherent 

Right handed 

HIGHER MENTAL FUNCTIONS Intact.

MMSE 24/30


CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : Visual acuity is normal

3rd,4th,6th : Pupillary reflexes present

               EOM full range of motion present        

5th : Sensory intact

          Motor intact

7th : There is absence of nasolabial fold in left side  and slight deviation of mouth towards right .

8th : No abnormality noted.

9th,10th,11th,12th : normal.


MOTOR EXAMINATION:

                           Right                        Left


                      UL          LL             UL      LL

 BULK:    Normal  Normal    Wasting in both 

TONE :   Normal  Normal  Hypertonic in both

 POWER :  5/5.         5/5.          3/5.          3/5


SUPERFICIAL REFLEXES:

CORNEAL present       

CONJUNCTIVAL present


DEEP TENDON REFLEXES:


                             Right                 Left


   BICEPS.               + 2                   + 3                 


   TRICEPS              + 2                   + 3                         


   KNEE                     + 3                   +3   


  ANKLE                   + 2                      +3


PLANTAR             Flexion                  Extension  

https://youtube.com/shorts/MWi6csdneKI?feature=share4


https://youtube.com/shorts/L9VKzyXRt_w?feature=share4


https://youtube.com/shorts/3R5VfOPGimY?feature=share4

    


SENSORY EXAMINATION:  


SPINOTHALAMIC SENSATION:

Crude touch Present 

Pain Present 

Temperature Present 

DORSAL COLUMN SENSATION:

Fine touch Present 

Vibration Present 

Proprioception Present 

CORTICAL SENSATION:


Two point discrimination Present 

Tactile localisation Present 

CEREBELLAR EXAMINATION:


 Finger nose test able to perform 

 Heel knee test able to perform

https://youtu.be/6IUtiGy19K0

Dysdiadochokinesia Absent 

Speech Normal 

Rhombergs test Absent


SIGNS OF MENINGEAL IRRITATION: 

Kernig's sign, brudzinski sign, neck rigidity

 absent 


RESPIRATORY SYSTEM:Bilateral air entry present,vesicular breath sounds heard, no adventitious sounds heard. 


CARDIOVASCULAR SYSTEM:

S1 ans S2 heart sounds heard,no murmurs heard 


ABDOMINAL EXAMINATION:

Soft and non tender,No organomegaly


PROVISIONAL DIAGNOSIS

Left Hemiparesis associated with UMN Facial palsy ( left side of face)

Acute ischemic stroke in right MCA territory??


INVESTIGATION


LIPID PROFILE

Total Cholesterol  152 mg/dL
Triglycerides # 172 mg/dL
HDL cholesterol # 39.7 mg/dL
LDL cholesterol 91.8 mg/dL
VLDL 34.4 mg/dL

COMPLETE BLOOD PICTURE

Haemoglobin 14.2 mg/dL
Total count 9000 cells/cu.mm
Neutrophils 60
Lymphocytes #19
Eosinophils #12
Basophils 0
Platelet count 2.79 lakhs / cu.mm
Smear Normocytic Normochromic 

RANDOM BLOOD SUGAR
125 mg/dl

SERUM CREATININE 1.1 mg/dL
BLOOD UREA 33 mg/dL

LIVER FUNCTION TESTS 

Total Bilirubin 0.98 mg/dL
Direct Bilirubin 0.18 mg/dL
SGOT 13 IU/L
SGPT 12 IU/L
Alkaline Phosphate #167 IU/L
Total proteins 6.7 gm/dL
Albumin 3.9 GM/dL
A/G 1.46

SERUM ELECTROLYTES

Na+ 135 mEq/L
K+ 4.4 mEq/L
Cl- 98 mEq/L
Ca+2 - 0.96 mmol/L


ECG


X RAY






Treatment

1. INJ OPTINEURON IV OD
(1 ampule in 100 mL NS)

2. TAB PREGABLIN 75mg po/HS

3. TAB ECOSPIRIN AV (75/20) po/Hs

4. TAB PAN 40mg po OD BBF

5. Physiotherapy of Left UL LL

BP PR RR charting 6th hrly









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