Short case 1

This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This E-blog also reflects my patient's centred online learning portfolio.

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 a diagnosis and treatment plan.

Following is the view of the case



60 years old male daily wage labourer by occupation was brought to the casuality with the 
1)Complaints of loss of speech since 2 days
2) Weakness of right upper limb since 2 days

3) Deviation of mouth to left side since 2 days


HOPI- 

He was apparently asymptomatic 2 days ago.Then he developed slurring of speech which was sudden in onset and  progressed to the present situation i.e.  complete loss of speech. (Aphasia)


He also developed weakness in his right upper limb at around 10:00 pm one day before admission.He is unable to move his right upper limb, (complete paralysis),It was sudden in onset. non- progressive in nature.

He developed mild deviation of mouth to Left side, since 2 days, which is sudden in onset. Non progressive in nature, Deviation was obvious during eating and when attempting smiling.Loss of nasolabial fold in the right side.


No h/o convulsions

No h/o headache

No h/o  unconsciousness

No h/o vomiting 


No h/o head injury

No h/o fever 

No h/o bowel and bladder disturbances 

No h/o chest pain

No h/o palpitations 

no h/o syncopal attacks.


Past h/o:

No history of similar complaints in the past.

Underwent cataract surgery for right eye last year in October. 

H/o trauma over the right wrist present 10 years back. He did not get any surgery for the fracture hence developed a malunion union of colles fracture in right upper limb.

Not a k/c/o DM,HTN, CAD, CVA,Epilepsy 


Personal h/o:

Consumes a Mixed diet. Sleep pattern is regular. Has a normal appetite.

He used to consume 250 ml of alcohol and 40 beedis per day since 15 years of age. Has reduced to 20 beedis/day in the last 5-6 years. 

Bowel and bladder habits are normal.


Married 35 years ago Has 2 children

Family h/o: No significant family history


General physical examination: he is conscious, cooperative, moderately built and moderately nourished.

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Edema.

GCS:15/15 











Vitals:


PR- 88 bpm, regular in rhythm, voluminous, felt in all peripheries, no radio-radial delay, no radio-femoral delay

BP- 110/80 mm Hg measured in left upper limb in supine position 

RR- 16 cpm, Thoraco-abdominal

Temperature- 98.4 degrees F

SpO2- 99% @ RA

GRBS- 106 mg/dl


NEUROLOGICAL EXAMINATION:


I) Higher mental functions- 

Patient is conscious, cooperative.

Speech : Motor aphasia 

Other findings could not be elicited.


II) Cranial nerves-

1- could not be elicited 

2-

i) Visual acuity – N 

2)Fundus . Normal

3,4,6- 


Test

Right eye

Left eye 

Extra-ocular movements- 

full in all directions 

full in all directions 

Pupil

Normal and symmetrical

Normal and symmetrical

Direct Light Reflex

Present

Present

Consensual Light Reflex

Present

Present 

Accommodation Reflex

Present

Present

Ptosis

No

Present

Nystagmus 

Absent

Absent

Horner’s syndrome

Absent

Absent


5- 

Test

Right

Left

Sensory -over face and buccal mucosa

Normal

Normal

Motor – masseter, temporalis, pterygoids

Normal

Normal

Reflexes- Corneal reflex 

Present

Present

Conjunctival reflex

Present

Present

Jaw jerk

Present

Present


7-


Right

Left 

Nasolabial fold.     

Absent

  Present 

Deviation of mouth  absent.    Present

b) Sensory – 

Test 

Right

Left

Taste of anterior 2/3rds of tongue(salt/sweet)

Could not be elicited

Could not be elicited 

Sensation over tragus

Could not be elicited

Could not be elicited 


c) Reflex – 


Test 

Right

Left

Corneal

Present 

Present 

Conjunctival

Present 

Present 


d) Secretomotor –

Moistness of the eyes/tongue and buccal mucosa present in both right and left sides.


8-


Test

Right ear

Left ear

Rinnes 

Could not be elicited 

Could not be elicited 

Webers 

Could not be elicited 

Could not be elicited 

Nystagmus 

Could not be elicited 

Could not be elicited 


9,10-


i) Uvula, Palatal arches, and movements- Centrally placed and symmetrical


Test

Right.       

Left

Gag reflex.        

Present

    Present



 


11-

Test 

Right.       

Left

trapezius

N

N

sternocleidomastoid

   N                N 

  



12 

Test

Right

Left

Tone

Normal

  Normal

Wasting

No

No

Fibrillation 

No

No

Tongue Protrusion to the midline and either side

Normal  

Normal


III) Motor system:


A) Bulk

Right

Left

Inspection

Normal

Normal 

Palpation

Normal 

Normal

Measurements: upper limb 10cm above and below acromion



Lower limb 18 cm above and 10 cm below tibial tubercle



B) Tone

Rt

Lt

Upper limbs

Decreased. 

Normal 

Lower limbs

Normal 

Normal

C) Power 

Right upper limb       0/5

Left upper limb.        5/5

Right lower limb.      4/5

Left lower limb.        5/5




 



D) Reflexes:



  Superficial:



   - Corneal.   Normal



   - Conjunctival.   Normal



   - Abdominal : absent



   - Plantar   :  RT :extensor

Lt: flexor


  Deep Tendon:

Rt

Lt

   - Biceps

+++

++

   - Triceps

+

+

   - Supinator

++

+

   - Knee jerk

++

++

   - Ankle jerk   

+

+

   - Clonus.    Absent






Gait : circumduction gait



G) Involuntary movements 

Absent



IV) Sensory system- could not be elicited


V) CEREBELLAR SIGNS-

Titubation absent

Nystagmus absent

Hypotonia absent

Rebound phenomenon absent

Intention tremor absent

Pendular knee jerk absent


VI) AUTONOMIC NERVOUS SYSTEM

Postural Hypotension absent

Resting tachycardia absent

Abnormal sweating absent


VII) SIGNS OF MENINGEAL IRRITATION

Neck stiffness absent

Kernig’s sign negative

Brudzinski’s sign   negative



EXAMINATION OF OTHER SYSTEMS:-


 CARDIOVASCULAR SYSTEM:  


JVP not raised

Apex normally placed, 

no Palpable P2,

 Heart sounds –s1s2 present  normal, No thrills/murmurs


B) RESPIRATORY SYSTEM:

Chest - symmetrical, No paradoxical movements

Normal vesicular breath sounds heard

No abnormal/added sound


C) ABDOMEN:

 Abdomen is soft

No organomegaly

No ascites

Per-rectal examination- NAD


Investigations:-


CBP:


Hb- 14.2 gm/dl

TLC-13,000/cu. mm 

PLT - 2 lakhs/cu. mm

RBS- 112 mg/dl

BGT- O positive

BT-2 min 30 sec

CT -4 min 20 sec


LFT:

TB - 1.20 mg/dl

DB-0.30 mg/dl

AST-34 IU/L

ALT-39 IU/L

ALP- 608 IU/L

TP -7.5 gm/dl

Albumin - 3.9 gm/dl


RFT:

Urea- 35 mg/dl

Creatinine- 1.1 mg/dl

Uric acid- 5.1 mg/dl

Calcium- 9.2 

Phosphate- 3.6

Sodium- 135

Potassium- 4.7

Chloride- 99


CUE:

Colour - pale yellow

Appearance-clear

sp.gravity-1.010

Albumin : +

Sugar -nil

pus cells- 4-5


USG abdomen - Done in outside hospital at 13/05/2022 

Impression: 

- Altered hepatic echotexture with multiple hetero echoic lesions -?nature.

- Left renal calculi

- Left renal cortical cyst




ECG- 







2D Echo- 












CXR- PA VIEW:



























CT Brain-

Multiple acute infarcts in both cerebral hemispheres & right cerebellum- Suggestive of embolic stroke.







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