55year old male with recurrent CVA with k/c/o HTN since 3 years

 Dr.N.Deepa , Internee

Roll no. 105

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. 

Date of admission : 7/06/2023

CASE:

Patient was brought to the casualty with complaints of inability to speak since 6 hrs, weakness in right upper and lower limb since 6 hrs and deviation of angle of mouth to left since 6hrs.

HOPI : 

Patient was apparently asymptomatic 6hrs back ,then he developed inability to speak since 6 hrs, weakness in right upper and lower limb since 6 hrs and deviation of angle of mouth to left since 6hrs.

No h/o loss of consciousness, drooling of saliva

No h/o fever, seizures, vomiting,loose stools.

Past history:

History of CVA 2 years back.Around 5-6am in the morning he got up and was getting ready to go for work.But he couldn't button his shirt and observed weakness of right upper limb.He was admitted in a local hospital and his weakness improved in a week.Complete recovery took around 2-3 months. Later he did his day to day activities.Used medication for 6 months and stopped later.

History of hydrocele surgery 6months back

K/c/o HTN since 3 years (not on medication)

N/k/c/o DM

Personal history:

Mixed diet,normal appetite,sleep Adequate,bowel and bladder movement regular

Addictions - alcoholic and smoker for 30 years

Alcohol 2-3 times in a week

Beedis - 10/day

FAMILY HISTORY :

No history of diabetes or hypertension in the family.

GENERAL EXAMINATION :

Patient is examined in a well lit room after taking the consent. 

He is conscious, coherent and cooperative. 

Pallor - absent                

Icterus - absent 

Cyanosis - absent

Clubbing - absent

Generalized Lymphadenopathy - absent

Bilateral pedal edema - absent

VITALS :

Pulse - 88 beats per minute, regular in rhythm, normal in volume and character of vessel, no radio- radial delay, no radio - femoral delay. 

Respiratory rate - 24 cycles per minute

Blood pressure - 130/80 mm of hg, measured in the left arm in supine position

Temperature - 97.8F

Spo2 - 98% at room air

TEMPERATURE CHARTING:

SYSTEMIC EXAMINATION : 

CVS : 

    

S1 S2 heard, no murmurs

CNS : 

GCS- E4 V1 M6

Pupils - B/L NSRL

Reflexes

      Rt     Lt

B - 3+.    3+

T - 3+.     3+

S- 2+.     2+

K - 3+.     3+

A - 2+    2+

Plantar 

Right-Extensor  Left-Flexor 

Tone- normal in all 4 limbs

Power - 2/5 in right upper and lower limb

4/5 in left upper and lower limb 

RS :

Bilateral air entry present

ABDOMINAL EXAMINATION : 

Soft,non tender,bowel sounds+

INVESTIGATIONS:

DIAGNOSIS:

Right hemiplegia with acute infarct in left frontal and temporal lobe with chronic lacunar infarcts in bilateral capsuloganglionic region with aspiration pneumonia with hypokalemia( secondary to ? Nutritional) with Hypertension since 3 years

TREATMENT:

1.Ryles tube feeds- 200ml water hrly,200ml milk 4rth hrly

2.IV FLUIDS NS, RL @ 50 ml/hr 

3.TAB. ECOSPRIN 75mg RT OD

4.TAB.CLOPIDOGREL 150mg RT/OD

5.TAB.ATORVASTATIN 40mg RT/OD 

6.Tab.AMLONG 5mg PO OD 

7.Physiotherapy

8.Monitor vitals

9.Position change 2nd hourly