45 year old male

This is an online E logbook to discuss our patients' 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 the available global online community of experts intending to solve those patients clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name: G Sai Manogna

Roll no 41

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.

Following is the view of my case :

CASE PRESENTATION:

A 45 year old male who is a construction worker by occupation resident of nalgonda came to the casualty with the chief complaints of

  • C/o weakness of right upper limb since morning
  • C/o deviation of mouth to left since morning
  • C/o weakness of right lower limb since morning
Patient was apparently asymptomatic till yesterday 11 pm and then had 2 to 3 episodes of vomitings having food particles as content and non blood stained, and then without any medication vomitings got subsided and patient was normal till 8 am the next day

Then the next day he experienced sudden weakness of his right upper limb and was unable to button his shirt
He also complained of slurring of speech, sudden in onset and gradually progressing

This is associated with deviation of angle of mouth towards left while speaking, eating and showing teeth
And then later he developed drooling of saliva

Followed he also experienced weakness of his right lower limb and he was unable to wear and grip his slippers

No history of loss of sensation, pain, burning micturition
No h/o change in smell sensation, double vision, loss of vision, reduction in vision field
No h/o loss of sensation on face, drooping of eyelids
No h/o urinary or fecal incontinence
No h/o loss of consciousness
No h/o headache, fever
No h/o head/spine trauma
No h/o chest pain, breathlessness, palpitations

Past history
No history of similar complaints in the past
Not a known case of HTN, DM, asthma, TB, epilepsy
No history of prior surgeries
No known allergies

Personal history
Diet- Mixed
Appetite- Normal
Bowel and bladder movements- Regular
Sleep- Adequate
Addictions- 
He is a chronic alcoholic since 20 years
Consumes whisky 90 ml each day
He is chronic smoker since 20 years
Smokes beedi 2 packs daily

Drug history
No history of use of any medicines without presecription

Family history
No similar complaints in the family

Provisional diagnosis
Left MCA territory ischaemic stroke involving left parieto occipital and part of frontal lobe













FM ratio
MARC-  25-0.4= 24.6 cms
Umbilicus- 70 cms
ASIS- 82 cms
Waist to hip ratio



General examination
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, not cooperative but well oriented to time, place and person
Patient is well nourished and moderately built
 

No history of pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy

Vitals
Temperature- Afebrile
Blood pressure- 120/80 mm of Hg
Pulse rate- 78 bpm
Respiratory rate- 18 cpm
SpO2- 98% at room air


CVS- S1, S2 heard
RS- Bilateral air entry present

Systemic examinaion
CNS-

Higher mental functions
1.Higher mental functions intact

Patient is conscious
oriented to time, place and person
dysarthria( difficult or unclear articulation of speech)
Memory- Immediate, recent, remote- Intact
No delusions, hallucinations
No emotional lability

Cranial nerves

Test.                            Right.                  Left
1. Sense of.                    +                         +
    smell

2. Visual acuity
a. Near vision.              6/6.                    6/6
b. Distant vision.           N.                        N
c. Colour vision.            N.                        N
d. Confrontation.           N.                       N 
 test

3. a. Direct.                 N.                      N
    light reflex
    b. Indirect.             N.                      N
    light reflex 
c. Accommodation.  N.                      N
    reflex
d. Extra ocular.              N.                        N
     muscles

5. Sensory
    Touch.                    Present.           Present      Pain.                       Present.           Present

    Motor
Massetter.                    N.                         N
Temporalis.                  N.                         N
Pterygoid.                     N.                         N
Corneal reflex.           Present.           Present
Jaw jerk.                     Present            Present

7. Motor
a. Frontal belly of.            N.                       N
occipito frontalis
b. Orbicularis oculi.          N.                        N
c. Buccinator.                    N.                        N


Taste sensation of.        N.                       N
anterior 2/3 of 
tongue

8. Rinne's test.                N.                       N
    Weber test.                 N.                       N  

9. a. Hoarseness of.      N.                     N
Voice
b. Uvula and palatal arch N.              N
Movements
c. Gag reflex                    N.                  N
  
11. a. Sternocleidomastoid  N.           N      b. Trapezius.                  N.                  N

12. a. Fasciculations of    No               N
 tongue
b. Wasting.                          No             No


Examination of motor system




Examination of sensory system



Investigations













MRI








Ultrasound

ECG

Chest xray




Temperature charting





Day 1
S
Weakness of right upper limb
Deviation of mouth to left side
Weakness of right lower limb

O
Patient is conscious, coherent, non cooperative
Temp afebrile
BP- 120/80
PR- 74 bpm
RR- 16 Cpm
CVS- S1 S2+
CNS-
Tone                           Right.          Left
Upper limb                 N                   N
Lower limb                 N.                  N

Power.                       Right.            Left    
Upper limb                 3/5                 5/5
Lower limb                 4/5                 5/5

Reflexes                     Right.            Left
Biceps                            +                    -
Triceps                          -                     -
Supinator                     -                     -
Knee                             +++               ++
Ankle                          -                      +
Plantar.                  Extensor.        Flexion
A
Left MCA territory ischaemic stroke involoving left parietooccipital and part of frontal lobe

P
1. Inj. Thiamine 1 amp in 100 ml NS/IV/OD
2. Tab. Ecosprin 75 mg/PO/OD
3. Tab. CLOPITAB 75 mg/PO/OD
4. Tab. ATORVAS 40 mg/PO/H/S
5. RT FEEDS- Free water 100 ml 2nd hourly
Milk 2nd hourly 100 ml
6. BP, Temp, PR monitoring 4th hourly


Day 2
S
Weakness of right upper limb
Deviation of mouth to left side
Weakness of right lower limb

O
Patient is conscious, coherent, non cooperative
Temp afebrile
BP- 120/80
PR- 74 bpm
RR- 16 Cpm
CVS- S1 S2+
CNS-
Tone                           Right.          Left
Upper limb                 N                   N
Lower limb                 N.                  N

Power.                       Right.            Left    
Upper limb                 3/5                 5/5
Lower limb                 4/5                 5/5

Reflexes                     Right.            Left
Biceps                            +                    -
Triceps                          -                     -
Supinator                     -                     -
Knee                             +++               ++
Ankle                          -                      +
Plantar.                  Extensor.        Flexion
A
Left MCA territory ischaemic stroke involoving left parietooccipital and part of frontal lobe

P
1. Inj. Thiamine 1 amp in 100 ml NS/IV/OD
2. Tab. Ecosprin 75 mg/PO/OD
3. Tab. CLOPITAB 75 mg/PO/OD
4. Tab. ATORVAS 40 mg/PO/H/S
5. RT FEEDS- Free water 100 ml 2nd hourly
Milk 2nd hourly 100 ml
6. BP, Temp, PR monitoring 4th hourly


Day 3
S
Weakness of right upper limb
Deviation of mouth to left side
Weakness of right lower limb

O
Patient is conscious, coherent, non cooperative
Temp afebrile
BP- 120/80
PR- 74 bpm
RR- 16 Cpm
CVS- S1 S2+
CNS-
Tone                           Right.          Left
Upper limb                 N                   N
Lower limb                 N.                  N

Power.                       Right.            Left    
Upper limb                 0/5                 5/5
Lower limb                 0/5                 5/5

Reflexes                     Right.            Left
Biceps                            -                     -
Triceps                          -                     -
Supinator                     -                     -
Knee                             +                     +
Ankle                          -                      +
Plantar.                  Extensor.        Flexion
A
Left MCA territory ischaemic stroke involoving left parietooccipital and part of frontal lobe

P
1. Inj. Thiamine 1 amp in 100 ml NS/IV/OD
2. Tab. Ecosprin 75 mg/PO/OD
3. Tab. CLOPITAB 75 mg/PO/OD
4. Tab. ATORVAS 40 mg/PO/H/S
5. RT FEEDS- Free water 100 ml 2nd hourly
Milk 2nd hourly 100 ml
6. BP, Temp, PR monitoring 4th hourly


Day 4
S
Weakness of right upper limb
Deviation of mouth to left side
Weakness of right lower limb

O
Patient is conscious, coherent, non cooperative
Temp afebrile
BP- 120/80
PR- 74 bpm
RR- 16 Cpm
CVS- S1 S2+
CNS-
Tone                           Right.          Left
Upper limb                 N                   N
Lower limb                 N.                  N

Power.                       Right.            Left    
Upper limb                 0/5                 5/5
Lower limb                 0/5                 5/5

Reflexes                     Right.            Left
Biceps                            -                     -
Triceps                          -                     -
Supinator                     -                     -
Knee                             +                     +
Ankle                          -                      +
Plantar.                  Extensor.        Flexion

A

Left MCA territory ischaemic stroke involoving left parietooccipital and part of frontal lobe

P
1. Inj. Thiamine 1 amp in 100 ml NS/IV/OD
2. Tab. Ecosprin 75 mg/PO/OD
3. Tab. CLOPITAB 75 mg/PO/OD
4. Tab. ATORVAS 40 mg/PO/H/S
5. RT FEEDS- Free water 100 ml 2nd hourly
Milk 2nd hourly 100 ml
6. BP, Temp, PR monitoring 4th hourly


Day 5
S
Weakness of right upper limb
Deviation of mouth to left side
Weakness of right lower limb

O
Patient is conscious, coherent, non cooperative
Temp afebrile
BP- 110/70
PR- 78 bpm
RR- 16 Cpm
CVS- S1 S2+
CNS-
Tone                           Right.          Left
Upper limb                 N                   N
Lower limb                 N.                  N

Power.                       Right.            Left    
Upper limb                 0/5                 5/5
Lower limb                 4/5                 5/5

Reflexes                     Right.            Left
Biceps                            -                     -
Triceps                          -                     -
Supinator                     -                     -
Knee                             +                     +
Ankle                          -                      +
Plantar.                  Extensor.        Flexion

A

Left MCA territory ischaemic stroke involoving left parietooccipital and part of frontal lobe

P
1. Tab. Thiamine 100 mg/PO/OD
1. Tab. Ecosprin 75 mg/PO/OD
2. Tab. CLOPITAB 75 mg/PO/OD
3. Tab. ATORVAS 40 mg/PO/H/S
4. BP, Temp, PR monitoring 4th hourly

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