General medicine elog 2

Anahita behara 

roll no 08

This is an online e-log platform to discuss case scenarios of a patient with their guardian's permission.

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

ongoing case 

 A 75 year old male patient had come to the OP with complaints of left sided weakness and deviation of mouth to right side.

He has a history of diabetes and hypertension since the past 8 years

Patient was apparently asymptomatic until 5 pm yesterday (17/7/21)

 • At 5 pm - Could not hold the tea cup with his hands and spilled it all over him. Following which his wife applied lotion over his abdomen and they had dinner and watched TV.

 • At 2 am - He called his wife because he could not move his Left UL (upper limb) and he couldn’t talk properly and there was deviation mouth to the Right. He could not contain his urine - his wife recollects. (he arrived to the hospital with foley's catheter)

 • At 5 am - Went to a local hospital which diagnosed him with Left UL Monoplegia with RT sided  UMN (upper motor neuron) palsy 
CT scan was done

 • At 9 am - Pt arrived at our hospital. His complaints were the above but we also noticed that he had LT LL Weakness. Could swallow water when given in bottle caps

 • At 8 pm - Above complaints + decreased ability to swallow - RT was inserted

(Ryle’s tube : it is a nasogastric tube, It is used for short- or medium-term nutritional support)

No h/o fall or trauma, fever, epilepsy

H/o stopping his medication given for HTN 15 days ago (reason not clear)

No h/o similar complaints in past.

Occasionally consumed toddy, does not smoke / consume tobacco or beedi.

Diet - Mixed
Appetite - Normal
Sleep - Normal ,
Bowel and bladder - has not passed stools since yesterday

General Examination :
Pt was conscious, coherent and cooperative. He was oriented to time, place and person. Moderately built and nourished.

No pallor, Icterus, Cyanosis, Lymphadenopathy.

Vitals :
Afebrile
BP 160/100
PR  80
RR 16
SpO2 96%
GRBS  126

Respiratory System

 BAE + (Bilateral air entry ) , NVBS Heard, Trachea Central

Chest X-ray 

CVS

  S1 S2 Heard

 No murmurs

Per Abdomen :

 Soft and non-tender, Bowel sounds heard.

CNS :
Cranial nerves -  Normal except
Deviation of mouth to RT side and in-ability to shrug the left shoulder ;
Recently decreased ability to swallow
Sensory System - Normal
Motor System -
 • Power - Decreased in LT UL and LL
 • Tone - Decreased in LT UL and LL
 • Reflexes
                       RT.             LT.
B                     2+            2+
T                     2+            2+
S                     2+            2 +
K                     3+            3+
A                    1 +            1+
Plantar        Flexor.     Extensor

 

The following images show the slight flexion of the left upper and lower limbs

 hemogram , fasting blood sugar ,blood urea , Lipid profile , serum creatinine and serum electrolytes  

Neutrophils : 86% (normal range : 45%-80%) : slightly raised

Lymphocytes : 9% (normal range : 20%-40%) : decreased

Fasting blood sugar : 122mg/dl (70mg/dl – 100mg/dl) : increased

Blood urea : 37mg/dl (7-30mg/dl) : increased

Provisional Diagnosis :
CVA ;  LT Hemiparesis 2⁰ to ? Acute infarct in Rt Internal Capsule Rt MCA territory

Plan of management:
Admitted in AMC and following investigations were sent -
CBP, RFT, FLP, RBS, HbA1c, CXR PA view

Treatment:
1. T. ECOSPIRIN 150 MG OD / RT
2. T. CLOPITAB 75 MG OD/ RT
3. Inj. Optineuron 1 amp in 100 ml NS OD / i.v.
4. T. PAN 40 MG OD/ RT
5. T. ATORVAS 40 MG  OD/ RT
6. RT FEEDS - 100 ML WATER HOURLY AND 200 ML MILK 4TH HOURLY W/O SUGAR
7.   Inj. HAI s/c TID after GRBS
8. BP/PR/SpO2