FINAL PRACTICAL LONG CASE : Case of a 70 year old male with recurrent CVA

GENERAL MEDICINE - FINAL PRACTICAL EXAM

LONG CASE

Hallticket no: 1701006158

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.

CASE PRESENTATION:

This is a case of a 70 year old male who was cattle grazer by occupation came to the casuality with: 

CHIEF COMPLAINTS:

• Weakness in the right sided upper limbs and lower limbs since 3 days
• Slurring of speech since 3 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 years back, then he had experienced weakness in right upper and lower limbs. It was sudden in onset not associated with slurring of speech or drooling of saliva. Patient complained that he suddenly couldn't move his right upper and lower limbs while walking up the stairs. Then he was treated conservatively and weakness subsided completely. 

Then he experienced a similar attack 2 years back. He complained of weakness of right upper and lower limb associated with slurring of speech and drooling of saliva. He was treated and the weakness subsided . Patient was advised not to do heavy works. 

Presently he came with the similar complaint of weakness of right sided upper limb and lower limb and slurring of speech since 3 days. 

He was unable to recognize his family members. 

PAST HISTORY:

Known case of Hypertension since 1 year , been on regular medication since then ( Tab. Atenolol) 

Not a known case of Diabetes Mellitus, tuberculosis, asthma, epilepsy

PERSONAL HISTORY:

Diet: vegetarian diet predominantly

Appetite: Normal 

Sleep: Adequate

Bowel and bladder habits: Regular

Addictions: Used to consume alcohol occasionally

Stopped since 5 years

No known allergies

FAMILY HISTORY:

No H/O similar complaints in the family

GENERAL EXAMINATION:

Patient is examined in a well lit room after obtaining informed consent. 

Patient is conscious, incoherent and cooperative. 

Patient is moderately built and moderately nourished. 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema. 

VITALS:

Temperature: Afebrile

BP: 140/80 mmHg

Pulse rate: 72 bpm

Resp rate: 18 cycles/min

GRBS: 156 mg/dl

SYSTEMIC EXAMINATION:

CVS: S1 S2 heard, no murmurs

RS: Normal vesicular breath sounds heard

Per Abdomen: soft, non-tender, no organomegaly

CNS:

HIGHER MENTAL FUNCTIONS:

Conscious,cooperative but incoherent

Oriented to time, but not oriented to place and person.

Memory- not able to recognize family members

Speech - only comprehension, no fluency, no repetition

CRANIAL NERVES:

I- Olfactory nerve-  sense of smell present

II- Optic nerve- direct and indirect light reflex present

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis

V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.

VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.

VIII- Vestibulocochlear nerve- no hearing loss

IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised

XI- Accessory nerve- sternocleidomastoid contraction present

XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue

MOTOR EXAMINATION:

i) BULK:          Right              Left

   Arm           24.5cm           26cm

 Forearm       18cm             18cm

 Thigh            44cm             44cm

  Leg               28cm             28cm

ii) TONE:                  Right               Left

   Upper limbs       Decreased     Normal

   Lower limbs       Decreased     Normal

                          

iii) POWER:           Rt                Lt

  U/L

       Hand              0/5               4/5

       Elbow             0/5               4/5

      Shoulder         0/5               4/5

L/L

        Hip                0/5                4/5

      Knee               0/5                5/5

      Ankle              0/5                4/5

iv) REFLEXES:       Rt             Lt

            Biceps        3+              2+

          Triceps        3+              2+

       Supinator      3+               2+

            Knee          3+               2+

           Ankle          -                  -

        Plantar    Extension    Neutral

SENSORY EXAMINATION:

                                 Right           Left

 Crude touch        present       absent

 Fine touch           absent        present

           Pain            absent        present   

   Vibration          absent         present

Temperature      absent          present

Stereognosis       absent          present

2 pt discrimination: absent    present  

CEREBELLAR SIGNS: Normal

GAIT: Walks with support

No signs of meningeal irritation

INVESTIGATIONS:

CBP

• Hemoglobin- 12.6 gm/dl (N)
• PCV- 35.2 % (N)
• TLC- 8600/ cumm (N)
• RBC- 4.33 million/cumm (N)
• Platelets- 2.58 lakhs/ml (N)

Blood urea- 24 mg/dl (N)

Sr. creatinine- 1.3 mg/dl (N)

Sr. sodium- 136 mEq/L  (N)

Sr. potassium- 3.7 mmol/l (N)

Sr.chloride- 104 mEq/L (N)

LFT

Total bilirubin- 0.61 mg/dl  (N)

Direct bilirubin-  0.16 mg/dl (N)

SGPT- 11 (N)

SGOT- 13 (N)

ALP- 105 IU/L (N)

Albumin- 4 g/dl (N)

Bleeding Time:   2 min 30 sec

Clotting Time:    4 min 30 sec

ECG: 

MRI:

 2017:

2022:

PROVISIONAL DIAGNOSIS:

Acute ischemic stroke causing right sided hemiplegia (left MCA territory)

Recurrent CVA 

TREATMENT:

Tab. Ecosporine 150mg

Tab. Clopidogrel 75 mg

Tab. Atorvas 40mg

Tab. Atenolol 25mg

Physiotherapy