65 yr old male
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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.
Chief complaints:
C/o slurring of speech since today morning Deviation of mouth to Right side since today morning
Weakness of left upper limb since today morning
c/o pedal edema since 1 day
Hopi:
Patient was apparently alright 6months back then he had h/o loose stools 6-7 episodes daily low quanitity,yellow in colour not associated with pain abdomen,no mucus in stool,no blood in stool
H/o fever 2 episodes in the past 6 months and not releived by taking medication no h/o nausea,vomitings,h/o decreased appetite since 6 months
Patient brought to opd with c/o slurring of speech,deviation of mouth to right side and weakness of left upper limb since today morning .
Pt was normal when he woke up and he suddenly developed weakness of left UL ,slurring of speech and deviation of mouth to right side
No h/o cold ,cough,seizure,headache,blurring of vision,diplopia
C/o B/L pedal edema since 1 day , pitting type upto ankle ,decreased urine output since 3 days no burning micturition,no sob
Past illness:
K/c/o HTN Since 7years on medication (Telma-H 40mg)
N/K/c/o Dm,Epilepsy,Tb
Personal history:
Diet:Mixed
Appetite:Normal
Sleep:Normal
Bladder movts:decreased urine output since 3 days
Bowel movements:Normal
Habits:Drinks alcohol ocassionally in the past but stopped totally from 2 months
Smoker since 40years
General examination:
Patient is conscious,coherent,cooperative
Vitals:
Temp:Afebrile
Bp:140/80mmhg
Pr:88bpm
Rr:18cpm
Spo2:98%@RA
pallor+,No icterus,cyanosis,clubbing,lymphadenopathy
oedema-present upto ankle
Systemic examination:
Cvs-S1S2+,No murmurs
Rs-BAE+,Normal vesicular breath sounds heard
P/A:Soft,Non tender
CNS Examination:
Higher mental functions
- Conscious +
- Oriented to time+,place+ and person+
- Memory - Intact
- Speech - slurred
Cranial nerve examination
• 1 - olfactory sense - normal
• 2- visual acuity present,
R L
Direct reflex + +
Indirect reflex + +
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present
• 7- deviation of mouth to right, no loss of nasolabial folds, forehead wrinkling present
• 8- Normal hearing
• 9,10- position of uvula is central ,Gag reflex- present
• 11- sternocleidomastoid contraction present
• 12- no deviation of tongue
Motor system
Reflexes
Right Left
Biceps 2+ 1+
Triceps 2+ 1+
Supinator 1+ 1+
Knee. 2+ 2+
Ankle. 2+ 2+
Plantars- Flexor Flexor
Power. Lt. Rt
Upper limb -4/5. 4/5
Lower limb -4/5 4/5
TONE. Lt. Rt
Upper limbs hypo N
Lower limbs N N
No Involuntary movements
SENSORY SYSTEM
I – SPINOTHALAMIC R L
1. Crude touch N N
2. Pain. N. N
3. Temperature. N. N
II – POSTERIOR COLUMN
1. Fine touch. N. N
2. Vibration. N. N
3. Position sense. N. N
4. Romberg’s sign -Negative
III – CORTICAL
1. Two point
discrimination. N. N
2. Tactile localisation. N. N
3. Graphaesthesia. N. N
4. Stereognosis. N. N
CEREBELLAR Tests
No Nystagmus
Finger Nose test -
right - normal ,left -cannot be elicited
Heel Knee test - right - normal ,left - cannot be elicited
Dysdiadokokinesia -
cannot be elicited
Investigations:
Mri brain:
HEMOGRAM:
CUE:
LFT:
CHEST X RAY PA VIEW:
ECG:
2D ECHO:
USG ABDOMEN:
Diagnosis:
CVA
TREATMENT:
T.CLOPIDOGREL 75 MG PO/OD
T.ECOSPRIN 75MPO/OD
T.ATORVOSTAT 20MG PO/OD
INJ.OPTINEURON in 100ml NS IV STAT
INJ.ZOFER 4MG IV STAT
IV FLUIDS NS,RL@100ml/hr
