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OBSERVATIONS:
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
CHEIF COMPLAINTS:
A 79 y/o male was brought to casuality with c/o cough since 1 & half month ,
difficulty in swallowing and h/o Aspiration pneumonia since one month
fever since 10 days
C/o altered sensorium since 3 days
HOPI
Patient is a known case of cva with left hemiplegia,
Patient was apparently asymptomatic one and half month back when he developed cough insidious in onset and gradually progressive. PRODUCTIVE but patient is not able to spit it out. Difficulty in swallowing.
H/o cough on intake of liquids.
H/o change of voice since 20 days, insidious, hoarse in character and
SLURRING OF SPEECH +present
No h/o difficulty in breathing, breathlessness, hemoptysis
Fever since 10 days -high grade. O/e Chills and rigors + (38 spikes).
H/O WEAKNESS in LEFT upper and lower limb since 7 years aggrevated since 4 days.
No/h/o vomiting, chest pain, loose stools.
PAST HISTORY
Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is on medications I.e tab TELMA AM 40mg po/od. Tab zoryl mv , po/od
History of events:-
• 10 years back , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication.and after 1 year ,with regular check up he was found to be Hypertensive and started on antihypertensive medication.
• 7 years back, patient developed head ache at around evening 7pm and followed by vomtings, he had weakness and itching of left hand over that night and he couldn't sleep.
next day morning he was taken to hospital he couldn't hold any objects and movements decreased on his left hand and was found to habe infracts in brain, so started on antiplatlets after 3 dayssstay in the hospital he became left sided hemiplegic. He was admitted in hospital for one and half month and discharged later. He only took liquid foods for 3 months and took solid foods later.
Patient used get urinary tract infections total no of times (5-6). It got subcided after 5 days after using medication
Patient had 2 attacks with covid 19
1st one : 2020 used medication at home subsiced after 5 days
2nd attack: 2021 admitted in hospital and treated subcided after a week
K/c/o seizures since 2 years; total no of episodes 3
1st episode 2 years back which is for 5 minutes patient eyes got rolled up and froth from mouth is noticed.patient is made to roll on his left ,seizures got subcided
Next day morning he was taken to hospital after 3 hours stay in the hospital he got 2nd episode episode of seizures for 5 minutes, medication was given
3rd episode has occurred after 3 hours in the hospital stay for 2 minutes
• From 7 years onwards , patient was bedridden with foleys (changed every 15 days) and physiotherapy was done by his attenders daily, but there was no such improvement.
K/c/o CVA with left hemiplegia since 7 years.
K/c/o seizures disorder since 2 years for which on medications Tab levipil 500mg
K/c/o hypothyroidism since 5 years on thyronorm 25mcg.
• 20 days back, from March 1st onwards ,patient developed slurring of speech and decreased responsiveness and cough ( mild ) and unable to clear the throat secretions and was taken to the hospital and was treated with antibiotics and patient was brought here for further evaluation.
PERSONAL HISTORY
Appetite lost,
Mixed diet
Bowel- constipated,
Bladder regular
No known allergies and Addictions.
i.e non alcoholic and non smoker
Family History- not any
Treatment history
•Tab TELMA AM 40mg po/od since past 10years
•Tab zoryl mv , po/od
•Tab levipil 500mg since 2 years
• thyronorm 25mcg. Since5 years
GENERAL EXAMINATION
O/e PT IS arousable but not oriented.
Pt not cooperative mostly.
-PALLOR: PRESENT
-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
VITALS ON ADMISSION
PR-90 BPM
BP- 140/80MM HG
RR- 22 CPM
SPO2- 98% AT RA
GRBS - 183mg/dl
SYSTEMIC EXAMINATION:
Respiratory :-
Inspection : respiratory movements equal on both sides
Trachea central
palpation : apical impulse in left 5th intercostal space
Auscultation : normal vesicular breath sounds
Percussion- BAE+
CNS:
PATIENT is unconscious incoherent uncooperative
HIGHER MENTAL FUNCTIONS- cannot be elecited
Speech
Behaviour
Memory
Intelligence
Lobar functions
GCS
E3V3M5
B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT
NO SIGNS OF MENINGEAL IRRITATION,
CRANIAL NERVES
2nd cranial nerve
Visual acuity is decreased on left side
3rd 4th 6th pupillary reflex present
SENSORY SYSTEM- cannot be elicited
Spinothalamic sensation:
Crude touch
Pain
Temperature
Dorsal column sensation
Fine touch
Vibration
Propioception
Cortical sensation
Two point discrimination
Tactile localisation
Stereognosis
Graphathesia
MOTOR EXAMINATION:
Right left
UL. LL. UL. LL
BULK : Normal Reduced
TONE. Normal Hypotonia
POWER. Could not be elicited
SUPERFICIAL REFLEXS
plantar reflex
Left side babinski sign positive
SUPERFICIAL REFLEXS
PLANTAR REFLEX RIGHT SIDE
https://youtube.com/shorts/PGMIKKzz2Hw?feature=share
PLANTAR REFLEX LEFT SIDE
https://youtube.com/shorts/8ypC55k167o?feature=share
ABDOMINAL REFLEX :
https://youtube.com/shorts/G8LUD3cPuIU?feature=share
DEEP TENDON RELEXES
BICEPS LEFT SIDE
https://youtube.com/shorts/zJ2G4oYLd78?feature=share
TRICEPS LEFT SIDE
https://youtu.be/VJRNW3RE-G8
SUPINATOR LEFT SIDE
https://youtube.com/shorts/WEasWwhJU2I?feature=share
JAW JERK REFLEX:
https://youtube.com/shorts/zae1ecxT9bM?feature=share
KNEE JERK REFLEX RIGHT SIDE
https://youtube.com/shorts/7vpvVXW9110?feature=share
KNEE JERK REFLEX LEFT SIDE
https://youtube.com/shorts/2ObgP9VAi00?feature=share
ANKLE REFLEX RIGHT SIDE
https://youtube.com/shorts/PGMIKKzz2Hw?feature=share
ANKLE REFLEX LEFT SIDE
https://youtube.com/shorts/UprL85E5ZLw?feature=share
CLONUS
https://youtu.be/DMwGFTZOms0
CEREBELLAR EXAMINATION : cannot be elicited
Finger nose test
Heel knee test
Dysdiadochokinesia
Dysmetria
hypotonia with pendular knee jerk present.
Intention tremor present.
Rebound phenomenon .
Nystagmus
Titubation
Speech
Rhombergs test
SIGNS OF MENINGEAL IRRITATION: absent
GAIT: patient unable to walk
CVS
ASCULTATION: S1S2 +,NO MURMURS
P/A
INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS
AUSCULTATION: no bowel sounds heard
bed sores
Clinical images
bed sores
C/o asymptomatic lesions all over the body since 2 months
H/o application of unknown topical medications used
O/e multiple hyperpigmented Macclesfield present all over the body with scaly lesions over the upper back
•Diffuse xerosispresent
• single ulcer of size 1.5x1.5 cms (approx) over the back.
Diagnosis SENILE XEROSIS + post inflammatory hyperpigmentation.
( +? TROPHIC ULCER )
INVESTIGATIONS :
MRI BRAIN:
• Large area of encephaolomalacia in right occipito -temporo lobes and righ parietal lobes.
• Prominence of sulci and cisterns.
• Bilateral periventricular hyperintensity.
• Rest of the Cerebral parenchyma shows normal gray/white matter differentiation.
• Basal ganglia and Thalami are normal.
• Brain stem normal.
• Cranio-vertebral and Cervico-medullary junctions are normal.
• Sella, pituitary and parasellar regions are normal. Stalk and hypothalamus are normal. Posterior pituitary bright spot is normal.
• No evidence of abnormal calcifications, vascular anomalies on SWI sequences.
IMPRESSION:
• Large area of encephalomalacia in right occipito-temporo lobes and right parietal lobes - sequelae of old infarct.
• Diffuse cerebral atrophy. Chronic small vessel ischemia.
Note: Poor quality of images due to motion artefacts
INVESTIGATIONS:
Anti HCV antibodies rapid -nonreactive
Blood urea -30mg/dl
HBA1C-6.7%
HbsAg rapid - negative
HIV 1/2 RAPID TEST - NON REACTIVE
TOTAL BILIRUBIN -0.81mg/dl(normal-0 to 1mg/dl)
Direct bilirubin-0.17mg/dl(0 to 0.2mg /dl)
Serum creatinine -0.9 mg/dl (0.8 to 1.3 mg /dl)
INVESTIGATIONS:
Anti HCV antibodies rapid -nonreactive
Blood urea -30mg/dl
HBA1C-6.7%
HbsAg rapid - negative
HIV 1/2 RAPID TEST - NON REACTIVE
TOTAL BILIRUBIN -0.81mg/dl(normal-0 to 1mg/dl)
Direct bilirubin-0.17mg/dl(0 to 0.2mg /dl)
Serum creatinine -0.9 mg/dl (0.8 to 1.3 mg /dl)
CUE :-
AFB-TRACE
PUS CELLS -2-4
EPITHELIAL CELLS -2-3
LFT
ABG
Ph 7.51
PCO2 29.5mmhg
Po2 67.5 mmhg
Electrolyte
Sodium 135meq/l
Potassium 3.5 meq/l
Chloride 98meq/l
Calcium -1.06 mmol/l
ECG
PROVISIONAL DIAGNOSIS
Recurrent CVA with Hypertension, T2 DM, seizures disorder.
TREATMENT
1) TAB ECOSPRIN 150 mg RT/OD
2) TAB CLOPIDOGREL 75 MG RT/OD
3) TAB ATORVAS 20 MG RT/OD
4) NEBULISATION - 3% NS ,
MUCUMZY 8th hourly
5) CHEST PHYSIOTHERAPY.
6) RT FEEDS 100 ML WATER 2nd HRLY
50 ML Milk 2nd HRLY.
8) TAB. THYRONORM 25MCG RT/OD
9) TAB. LEVIPiL 500 mg
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