General medicine
M.Yashwitha
Roll.no: 73
Case of left hemiplegia.
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 a diagnosis and treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.
Sequence of events:
2013- patient had complaints of polyuria ,went to hospital and was diagnosed diabetic.
Joint pains since 1week which was relieved on medication.
H/o of occasional shock like pain along shoulder(lt)since 6 months.
A 45 years old male Patient came to the casuality with complaints of deviation of mouth to right side since 27/5/23 night(after taking alcohol),weakness of left upper limb and lower limb since morning (28/5/23).
History of presenting illness:
Patient was apparently asymptomatic till 27/5/23 night ,then he developed deviation of mouth towards right side and on 28/5/23 morning had difficulty in walking due to which they visited a local hospital and was treated conservatively but symptoms did not subside and weakness progresses
-No h/o drooling of saliva.
-No h/o of loss of consciousness, nystagmus .
-No h/o of head trauma .
-h/o of low grade fever since 2days not associated with cough ,headache , vomitings.
-h/o alcohol consumption since 15 years.
-k/c/oDM since 10 years on tab.Glimi twice daily.
-N/k/c/o HTN (180/110mmhg@admission) CAD,thyroid ,epilepsy,bronchial asthma.
Personal history:
Diet: mixed
Appetite: normal
Sleep: Adequate
Bowel and bladder: Regular
Alcohol intake since 15-20 years (180 ml per day).
Examination :
General examination:
-Patient is conscious ,coherent , cooperative.
-No signs of pallor,Icterus,cyanosis,clubbing, lymphadenopathy and edema of feet.
-Temperature,:100°F
-Respiratory rate: 20 cycles/ min
-pulse rate: 108 beats/ min.
-BP: 280/100 mmHg.
Systemic examination:
*CVS:
- cardiac sounds: S1S2 +
- no cardiac murmurs.
*Respiratory system:
-position of trachea:central
-breath sounds:vesicular
- no dyspnea ,wheeze.
*Abdomen:
-shape of abdomen: scaphoid.
-tenderness: no
-no palpable mass,free fluid.
-liver: palpable.
-spleen: not palpable.
-bowel sounds :yes.
*CNS :
Neurological examination:
1).Higher Mental functions: intact
-consciousness
-orientation to time ,place,person
-speech and language.
-memory : immediate _retentionand recall,recent and remote.
-delusions , hallucinations: no
-emotional liability
-MMSE score:
- orientation: •date,day,month,season,year(5)
•floor,hospital, district,state,country.(5).
-Registration
• name 3 objects taking one second for each object.Ask him to repeat the same
•repeat till he remembers (3)
-Attention and calculation.
•serial7's 5 times.(5)
-Recall.
•recall the three objects(3)
-Language.
•name 2 objects (2).
•repeat a sentence (1).
Follow a 3 stage command (3)
•reading 'close your eyes' (1).
•writing a sentence(1)
•copy a design (1)
2).Cranial nerves :
Rt.Lower facial nerve weakness +[mouth deviation to Rt.]
Sensory system-Normal(fine and crude touch, proprioception,vibration)
3).Reflexes:
Superficial reflexes - Intact
Plantar flexion extension
Deep tendon reflexes -
Right. Left
-biceps. +2 +1
- triceps. +2 +1
-supinator. +1 +1
-ankle. +1 +1
-knee. +2 +1
4).Tone.
Upperlimbs. Normal. Hypotonic
Lower limb. Normal. Hypotonic
5).Power
Upper limbs 4/5 1/5
Lower limbs. 4/5 1/5
6)
Cerebellum
Romberg: negative
Finger nose in coordination :absent
Dysdidokinesia : absent
DIAGNOSIS:
Left hemiperesis secondary to acute infarct in right MCA territory,mainly fronto parietal operculum, parieto occipital region ,insular cortex.Adjacent corona radiation with k/c/o DM Type 2 since 10 years.
INVESTIGATIONS:
28/5/23
-RBS: 250.
-sr. Na:140
-K+:3.6
-Cl- :105
-Ca+² :1.09.
29/5/23.
-FBD :248
-HbA1c: 6.9
*Hemogram-
-Hb :16.2 gm
-TLC :8800
-platelets: 62000
LFT:
-TB :1.03
-DB: 0.22
-SGOT :27
-SGPT :20
-ALP :111
-Total proteins: 7.3
-Albumin: 3.95
-sr.creatinine: 0.7
-sr.Na+ : 143
-K+ :3.5
- Cl- :104
-Ca+2 :1.13
31/5/23.
-Hb : 17 gm
-TC : 11000
-Neutrophils :75
-Lymphocytes :14
-eosinophil :1
-platelets:2.35 lakhs.
-MCH :33
-MCHC :34.5
* ECG:
*Ultrasound:
*MRI:
*Colour Doppler 2D echo:
TREATMENT:
-inj.Thiamine 200mg in 100 ml NS IO/BD.
-Tab.Ecosprin.
-Tab.Amlodipine 5mg PO/OD.
-Tab.Ultracet.
-Tab Dolo650 mg PO/sos.
-Tab.Lorazepam.
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