45/M Left sided limb weakness , Right sided Mouth Deviation

 ​June 01, 2023

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


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.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Sequence of events:

2013- patient had complaints of polyuria ,went to hospital and was diagnosed diabetic.

Joint pains since 1week which was relieved on medication.

H/o of occasional shock like pain along shoulder(lt)since 6 months.


Patient was brought to causualty with c/o deviation of mouth to right side since yesterday night ,weakness of left upper limb and lower limb since morning ,patient was apparently asymptomatic  till yesterday night  ,then deviation of mouth towards right side and today morning patient had difficulty walking due to which they visited a local hospital and was treated conservatively and symptoms did not subside  and weakness progressed 

No h/o slurring of speech ,drooling of saliva 

No h/o loss of consciousness,nystagmus,

No h/o head trauma 

H/o fever ,low grade since 2days not associated with cough ,headache ,vomitings

H/o alcohol consumption since 15years 

K/c/o DM since 10years on tab glimi twice daily

N/k/c/o HTN(180/110)@admission ,CAD ,thyroid epilepsy.







Personal history:

Diet: mixed 

Appetite: normal

Sleep: Adequate 

Bowel and bladder: Regular 

Alcohol intake since 15-20 years (180 ml per day)

GENERAL EXAMINATION:

Vitals:

PR-105 bpm

RR- 25 cpm

Temp-99F

Bp-180/110 mmhg 

Spo2-98 RA 

GRBS-204 mg/dl

No pallor,No icterus, cyanosis, clubbing, lymphadenopathy,edema.

SYSTEMIC EXAMINATION ::

GIT

INSPECTION :

Abdomen - scaphoid 

Umbilicus - inverted 

Movements - all quadrants are equally moving with respiration.

No scars and sinuses 

No visible peristalsis

No engorged veins.

PALPATION:

No local rise in temperature and no tenderness in all quadrants 

LIVER: no hepatomegly

SPLEEN- not enlarged 

KIDNEYS - bimanual palpable kidneys 

PERCUSSION :

no shifting dullness

AUSCULTATION :

Bowel sounds are heard and are normal

No bruit

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical with pectum excavatum 

Type of respiration: thoraco abdominal.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- absent.

Vocal fremitus- normal on both sides.

Percussion:                   

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

Bilateral Airway entry - present

Cardiovascular system:

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

Central Nervous system:

Higher motor functions- Intact 

Cranial nerve functions - Rt.Lower facial nerve weakness +[mouth deviation to Rt.]

Sensory system-Normal(fine and crude touch, proprioception,vibration)

Motor system.             Right  Left    

                    Power- UL 4/5  1/5

                                 LL 4/5  1/5 

                              Neck  N     N

              Trunk muscles   Normal


                Tone- UL Normal  decrease

                         LL Normal     Decrease


          Reflexes- 

Superficial reflexes - Intact 

                    Plantar flexion  extension

Deep tendon reflexes -

                           Biceps   ++    +++

                           Triceps   ++   +++

                         Supinator  +   ++

                                Knee  ++   + ++

                             Ankle     +    ++

Cerebellum 

Romberg: negative

Finger nose in coordination :absent

Dysdidokinesia : absent

INVESTIGATIONS: 

















DIAGNOSIS:LEFT HEMIPARESIS 2o TO ACUTE INFARCT IN RT. MCA TERRITORY -MAINLY FRONTO PARIETAL OPERCULUM,PARIETO OCCIPITAL REGION ,INSULAR CORTEX , ADJACENT CORONA RADIATA;K/c/o Dm2 SINCE 10 YEARS.

TREATMENT :1. RT FEEDS 100 ml 2nd hourly

  MILK + PROTEIN POWDER 4 th hourly

 2.IV FLUIDS NS @ 25ml/hr

3.INJ.  THIAMINE 200 mg in 100 ml NS IV BD

4.INJ HAI ACC TO GRBS

5.TAB.ECOSPIRIN-AV (75/10)PO HS

6. TAB. AMLODIPINE 5mg PO/OD 8 am

7.TAB. DOLO 650MG PO SOS

8.T.LORAZEPAM 2mg 

9.T. BACLOFEN XL 20 mg 









Popular posts from this blog

INTERNSHIP COMPLETION ASSESSMENT -N.MANOHARA PRASAD

 1 DEC 2023 INTERNSHIP PERIOD : 5/5/23 to 3/7/23 NAME : N MANOHARA PRASAD  ROLL NO. :14  UNIT: 6    DURING MY INTERNSHIP IN GENERAL MEDICINE AT KIMS NARKETPALLY I HAD ENORMOUS OPPORTUNITY IN EXPLORING VARIOUS DEBILITATING DISEASES AND THEIR EFFECTS ON THE LIVELIHOOD OF PATIENTS,IN WHICH A FEW DEMANDED TIMELY INTERVENTION TO PREVENT THE VICTIM FROM GOING INTO “POINT OF NO RETURN”.WHILE THE OTHERS , HELPED ME WITNESSING A PLETHORY OF MANIFESTATIONS DUE TO UNDERLYING AND ONGOING DISEASE PROCESS. SUCH EXPOSURE ,BESIDES CULTIVATING SENSE OF PROMPT SYMPTOMATIC MANAGEMENT ,ALSO INTRIGUED ME TO INQUEST INTO ETIOLOGY AND ENHANCED CREDIBILITY OF EVIDENCE BASED MEDICINE . ICU & AMC DUTY: -  Monitored vitals of all pts hourly  -Learnt the importance of monitoring vitals -  Maintenance of ventilator settings as guided by the respective PG. -  Taken  ABGs and have taken samples for lab investigations. -  Learnt how to manage in critical situations  -Learnt to work under pressure  -Learnt the imp
Read more

GM case

Image
online blended bimonthly assignement for month of may 2021 94 N.Manohara Prasad 32yr old male with fever and headache March 30, 2022 32 yr old male with fever and headache This is an online E log book to discuss our patient's 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 available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box. A 32yr old male was brought to casualty with  --fever since 1 week. -Headache since  5 days HISTORY OF PRESENTING ILLNESS: Patient was apparently asymptomatic 1 week back. Then he developed fever which is moderate to high grade, intermittent ( on and off). He visited a local  RMP and took medication. There was mil
Read more