79 y/o male with Recurrent CVA and left hemiplegia with seizures

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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 diagnosis and treatment plan 

Chief complaints-

Cough since 20 days , 

Fever since 10 days

Difficulty in swallowing and h/o Aspiration pneumonia since one month

Altered sensorium since 3 days

History of Presenting illness

Patient was apparently asymptomatic 20 days ago.Then,he developed cough which was insidious in onset and gradually progressive,productive but patient was unable to clear throat secretions. He also had cold and drooling of saliva. He was treated with antibiotics till March 3rd

On March 5th, patient's wife noticed foaming at the mouth around 12 in the afternoon. He was admitted to a hospital in Nalgonda where he was treated with suction of throat secretions for 5 days. He was referred to this hospital for further evaluation

Difficulty in swallowing.

 H/o cough on intake of liquids.

 H/o change of voice since 20 days, insidious, hoarse in character and 

 SLURRING OF SPEECH +present

No h/o difficulty in breathing,  breathlessness, hemoptysis

 Fever since 10 days -high grade.

H/O WEAKNESS in LEFT upper and lower limb since 4 years aggrevated since 4 days.

 N/h/o vomiting, chest pain, loose stools.

PAST HISTORY  

 Patient is a k/c/o Hypertension and type 2 diabetes since past 10years for which he is  on medications I.e tab TELMA AM 40mg po/od.

K/c/o CVA with left hemiplegia since 7 years. 

   K/c/o seizures disorder since 2 years for which on medications Tab levipil 500mg

 History of events:-

-10 years back , patient developed lesions on his both foot and went to the doctor and found to have diabetes and started on medication.

-9 years ago he was diagnosed with hypertension and started taking anti hypertensives

 -7 years back, patient developed head ache at around evening 7pm and followed by vomtings, next day morning onwards patient became drowsy and cannot move his limbs and was taken to the hospital and found to have infarct and started on antiplatelets.

-From 7 years onwards , patient was bedridden with foleys (changed every 15 days) and physiotherapy was done by his attenders daily, but there was no such improvement.

-6 years ago he had a urinary tract infection and was treated with antibiotics for 5 days

- 2 years ago he had 2 episodes of seizures not lasting longer than 5 min

PERSONAL HISTORY 

Appetite reduced

Mixed diet

Bowel- constipated, 

Bladder regular 

No known allergies and Addictions.

Family History-  Not relevant

Treatment history   

 

•Tab TELMA AM 40mg po/od since past   10years

 •Tab zoryl mv , po/od

•Tab levipil 500mg since 2 years

GENERAL EXAMINATION 

O/w patient is conscious,incoherent and uncooperative 

-PALLOR: PRESENT

-NO PEDAL EDEMA, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS ON ADMISSION 

PR-90 BPM

BP- 140/80MM HG

RR- 22 CPM

SPO2- 98% AT RA

GRBS - 183mg/dl

SYSTEMIC EXAMINATION:

Respiratory :-

Inspection : Respiratory movements equal on both                         sides

palpation : Apex beat on left 5th intercoastal space 

Auscultation : NVBS heard

percussion - BAE +

                      

                 CNS

PATIENT WAS conscious,incoherent and uncooperative

HIGHER MENTAL FUNCTIONS- Could not be elicited

speech

Behavior

Memory 

Intelligence

Lobar Functions

No hallucinations or delusions.

Cranial Nerve Examinations

II- Visual acuity reduced on left side

3,4,6- Pupillary reflex present 

MOTOR EXAMINATION:                   

                             Right                                       left

                 UL.                LL.                     UL.      LL

   BULK     Normal      Normal               Reduced                            

   TONE           Normal                           Hypotonia

   POWER         Could not be elicited

MOTOR SYSTEM:

 B/L REFLEXES: 

BICEPS,  TRICEPS, SUPINATOR,  KNEE  ANKLE - hypotonia

 PLANTARS- hypotonia

SENSORY EXAMINATION:  Could not be elicited 

SPINOTHALAMIC SENSATION:

Crude touch

pain-

temperature

DORSAL COLUMN SENSATION:

Fine touch

Vibration

Proprioception

CORTICAL SENSATION:

Two point discrimination

Tactile localisation.

CEREBELLAR EXAMINATION

SIGNS OF MENINGEAL IRRITATION: absent

GAIT:

B/L PUPILS - NORMAL SIZE AND REACTIVE TO LIGHT

CVS

ASCULTATION: S1S2 +,NO MURMURS

P/A

INSPECTION: UMBILICUS IS CENTRAL AND INVERTED, ALL QUADRANTS MOVING EQUALLY WITH RESPIRATION,NO SCARS,SINUSES, ENGORGED VEINS, PULSATIONS.

AUSCULTATION: no bowel sounds heard

Clinical images

Investigations

CUE :-

AFB- Trace

Pus cells- 2-4

Epithelial cells- 2-3

ABG

PH-7.51 mmHg

pC02-29.5 mmHg

p02-67.9 mmHg

Urea-30mg/dL

HbA1c-6.7%

X Ray Chest

ECG

2D Echo

DIAGNOSIS 

Recurrent CVA with Hypertension, T2 DM, Thyroid disorder and seizures disorder

TREATMENT 

1) TAB ECOSPRIN 150 mg RT/OD

 2) TAB CLOPIDOGREL 75 MG RT/OD 

3) TAB ATORVAS 20 MG RT/OD

4) NEBULISATION - 3% NS ,

                                 MUCUMZY 8th hourly 

5) CHEST PHYSIOTHERAPY.

6) RT FEEDS 100 ML WATER 2nd HRLY

                        50 ML Milk 2nd HRLY.

8) TAB. THYRONORM 25MCG RT/OD

9) TAB. LEVIPiL TOOMG RT/OD

Credits

Durga Krishna Sir PG GM