45 year old male

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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