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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.
CASE:
A 40 year old male patient came to the casualty complaining of slurred speech and and weakness of bilateral upper and lower limbs.
History of presenting illness:
Patient was apparently asymptomatic 6 years back then he had slurred speech and paralysis of right hand and deviation of mouth to the left, and diagnosed with CVA and got treated in a local hospital and used some herbal medication for the same for 3 years and stopped. He is apparently alright since then.5 days back he had vomitings for 2 days (7 to 8 episodes per day) food as content for which he was treated in a local hospital.
Yesterday night on 4/7/2023 he again developed slurred speech and weakness in bilateral upper limbs and lowerlimbs due to which he is unable to walk and got admitted in local hospital where they have diagnosed them with CVA.
Past history:
Patient is a known case of CVA
Not a known case of Hypertension, DM, asthma epilepsy, CAD
Personal history:
Diet-mixed
Appetite-normal
Sleep-adequate
Bowel and bladder movements-regular
Addictions- alcohol intake since 30 years (90ml),decreased consumption since 6 years alcohol intake 10 days back. Tobacco chewing since 30 years.
Family history:
Not significant
General examination:
Patient is conscious,coherant, cooperative
Moderately nourished and ill built .
No pallor,Icterus, cyanosis, clubbing lymphadenopathy, edema
Vitals:
Afebrile
BP-140/70mmhgP8
PR-80bpm
RR-20cpm
Grbs-977mg/dl
Systemic examination:
Central nervous system:
Oriented to time,place,person
Speech: slurred
Cranial nerves:
1-intact
2- vision: normal
3,4,6- normal(no restriction of movements of eye)
5-normal( muscles of mastication+sensations of face)
7- buccinator weak on left side, deviation of mouth to Right.
8- didn't elicit
9,10,11,12-normal
Motor- tone -normal
Power- upper limb lower limbs
Right 4/5 5/5
Left 3/5 -4/5
Reflexes :
biceps: 3+ 3+
Triceps: 3+ 3+
Supinator: 3+ 3+
Knee: 3+ 3+
Ankle: 2+ 2+
Plantar: withdrawal extension
Sensory examination:
Spinothalamic tract: Right left
Crude touch + +
Pain + +
Temperature + +
Posterior column:
Fine touch + +
Vibration
Olecrenon 8 sec 9 sec
Supinator 7 sec 9 sec
Shaft of tibia 8 sec 9 30 sec
Medial malleolus 7 sec 7 sec
Joint position + decreased
Cortical:
Graphesthesia + +
Stereognosis + +
tactile sensation + +
Gait : ataxic gait
Provisional diagnosis:
Hemiparesis ( left>right ) secondary to acute infarct in left cerebellum.
K/c/o right upper limb monoplegia secondary to infarct in left parietal, occipital and thalamuc regions(resolving).
Treatment:
1. Inj. THIAMINE 200 mg Iv/stat
2. Tab. ASPIRIN 75 mg +CLOPIDOGREL 75 mg +ATORVASTATIN 20mg po/hs 9 pm
DISCHARGE SUMMARY:
Date of discharge:7-7-2023
A 40 year old male patient came to the casualty complaining of slurred speech and and weakness of bilateral upper and lower limbs.
Patient was apparently asymptomatic 6 years back then he had slurred speech and paralysis of right hand and deviation of mouth to the left, and diagnosed with CVA and got treated in a local hospital and used some herbal medication for the same for 3 years and stopped. He is apparently alright since then.5 days back he had vomitings for 2 days (7 to 8 episodes per day) food as content for which he was treated in a local hospital.
Yesterday night on 4/7/2023 he again developed slurred speech and weakness in bilateral upper limbs and lowerlimbs due to which he is unable to walk and got admitted in local hospital where they have diagnosed them with CVA.
Psychiatry referral done on 7-7-2023 i/v/o alcohol dependence:
Treatment:
1.patient and od were counseled and psychoeducated
2.Harmful effects of substances explained to patient and od.
3. Tab pregabalin 75mg x-------x------1
4. Tab. Benfothiamine 100mg x-------1-------x
5. Nico gums 2mg/SOS
Investigations:
CBP:
Haemoglobin 13.9gm/dl
TLC:8,100cells/cu mm
Platelet:2.02 lakhs/cumm
RFT :
S. Creat: 1mg/dl
Blood urea: 23mg/dl
Na: 139
Cl:101
K:4
LFT:
T. Bilirubin:1.14
D. Bilirubin:0.33
ALP: 141
AST:17
Albumin: 3.7
Rbs:110
Hba1c: 6.5g%
CT brain:
FINAL DIAGNOSIS:
Hemiparesis ( left>right ) secondary to acute infarct in left Sub cortical region
K/c/o right upper limb monoplegia secondary to infarct in left parietal, occipital and thalamic region(resolving).
1.Tab. ECOSPRIN GOLD (75,75,20mg) po/hs 9 pm
2. Tab pregabalin 75mg x-------x------1
3.Tab. Benfothiamine 100mg x-------1-------x
4. Nico gums 2mg/SOS
FOLLOW UP :
Review after 2 weeks to General medicine op and psychiatry op
SOAP NOTES:
07/07/2023
Ward :AMC
Unit : 3
DOA : 05/07/2023
A 40 year old male patient with slurred speech and weakness of b/l upper and lower limbs since 1day
S : slurred speech and weakness of b/l upper and lower limbs improved compared to yesterday
-Dry cough while drinking water.
-Stools passed 2 days back
O:
Patient is conscious coherent and cooperative
No pallor , icterus , clubbing, cyanosis, lymphadenopathy, oedema
Vitals :
BP- 140/70mmHg
PR -82 bpm
RR-20 cpm
Temperature -afebrile
GRBS-97mg/dl
Systemic examination:
CVS: s1,s2 heard ,no Murmurs,
RS:BAE,no added sounds ,NVBS,
P/A: soft, non tender,No organomegaly
Central nervous system:
Oriented to time,place,person
Speech: slurred
Cranial nerves:
1-intact
2- vision: normal
3,4,6- normal(no restriction of movements of eye)
5-normal( muscles of mastication+sensations of face)
7- buccinator weak on left side, deviation of mouth to left.
8- didn't elicit
9,10,11,12-normal
Motor- tone -normal
Power- upper limb lower limbs
Right 4/5 5/5
Left 3/5 -4/5
Reflexes :
biceps: 3+ 3+
Triceps: 3+ 3+
Supinator: 3+ 3+
Knee: 3+ 3+
Ankle: 2+ 2+
Plantar : withdrawal extensor
Sensory examination:
Spinothalamic tract: Right left
Crude touch + +
Pain + +
Temperature + +
Posterior column:
Fine touch + +
Joint position + decreased
Cortical:
Graphesthesia + +
Stereognosis + +
tactile sensation + +
A:
Hemiparesis ( left>right ) secondary to acute infarct in left Sub cortical region
K/c/o right upper limb monoplegia secondary to infarct in left parietal, occipital and thalamic region(resolving).
P:
1. Inj. THIAMINE 200 mg in 100ml NS Iv/BD
2. Tab. ECOSPRIN GOLD (75,75,20mg) po/hs 9 pm
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