PRE-FINALS
This is an online e log book to discuss our patient 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 centered 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 plan
55 Y/M with hemiparesis and tingling and burning sensation over left upper and lower limbs
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 6yrs ago then he had an episode of sudden loss of consciousness ( while he was working at around 9am) 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.
Patient complaints of generalized weakness since 1 year
He now presents with the complaint of burning sensation in the left upper and lower limb since 15 days which is persistent throughout day.
There is history of fall from bed due to which he developed a sudden right sided chest pain since 6days and is intermittent, dragging type , non radiating, which increases on inhaling and not associated with shortness of breath ,sweating .
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 theives)
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 catarct surgery 1 year ago .
PERSONAL HISTORY :-
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.
Diet: Mixed
Appetite: decreased (since 2 months)
Bowel - hard stools since last 10 days,
Bladder-regular
Sleep: inadequate
Addictions- Smoking since 40yrs ( one bidi packet per day)
he used to consume alcohol daily 180ml to 360 ml daily since 30 yrs , now he consumes occasionally
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.
Moderatly build and moderatly 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:
Olfactory : Normal
Optic: Visual acuity is normal
oculomotor,trochlear,abducens: Pupillary reflexes present , EOM full range of motion present
Trigeminal : Sensory intact
Motor intact
Facial n: There is absence of nasolabial fold in left side and slight deviation of mouth towards right
Vestibulocochlear : No abnormality noted.
Vagus, spinal accessory, hypoglossal n: normal.
MOTOR EXAMINATION:
Right Left
UL LL UL LL
BULK: Normal Normal Wasting in both
TONE : Normal Normal Hypertonic in both
POWER : RIGHT LEFT
ELBOW: 5/5 3/5
Flexion. 5/5 3/5
Extension: 5/5 3/5
Wrist: 5/5 3/5
Flexion: 5/5 3/5
Extension: 5/5 3/5
Abduction : 5/5 3/5
adduction: 5/5 3/5
KNEE :- 5/5 3/5
Flexion 5/5 3/5
Extension 5/5 3/5
ANKLE :- 5/5 3/5
Plantarflexion:. 5/5 3/5
Dorsiflexion 5/5 3/5
Toe 5/5 3/5
Movements:5/5
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
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
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 and S2 heart sounds heard,no murmurs heard
ABDOMINAL EXAMINATION:
Soft and non tender,No organomegaly
INVESTIGATION
PROVISIONAL DIAGNOSIS
Left Hemiparesis associated with UMN Facial palsy ( left side of face)
Acute ischemic stroke in right MCA territory??
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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