Right hemiparesis

 

A 75 year old male with weakness of right upper limband lower limb

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 .

K.shirisha

Rollno;60, 

9th semester

 

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 diagnosis and treatment plan

All the information has been collabated from Dr.shashikala mam and from patient.

Case discussion;

A 75 year old male daily wage labourer,and farmer by occupation presented to opd  on 18/10/21 at evening 7 pm .with complaints of decreased movements of right upper and lower limb,slurred speech , deviation of mouth to left .

History of present illness;

The patient was apparently well 11 years ago then he diagnosed as hypertension and diabetes 11 years ago.

10 years back he had shortness of breath which was sudden in onset associated with chest pain and he diagnosed as myocardial infarction and he underwent PTCA with?2 to DES(drug eluting shunt) to right coronary artery.and he was on tab Atorvastatin 20mg/od till now.

He was chronic cigerrate smoker for 40 years,and stopped after ptca

He never visited to hospital except for diabetes check up

C/O cough since 10 days non productive not associated with fever

Now cough associated with sputum, yellow in colour ,non blood tinged.

On 18/10/21; patient wake up at 6am and finished his daily routines.and he had his breakfast.and afternoon he had his lunch and he stayed at home not gone   to work. talked  to his wife .at7pm while patient was drinking tea,he had sudden onset of weakness of right upper limb and lower limb, deviation of mouth to left, with slurred speech,he phoned up his attenders upon their arrival ,,his Upper limb weakness was resolving and on bringing him to hospital deviation of mouth resolved.

History of past illness;

He is a k/c/o hypertension, diabetes since 11 years

K/c/o coronary artery disease since 10 years

He had pulmonary kochs 20 years back and used ATT for 6 months

Not a K/c/o bronchial asthma, epilepsy.

Treatment history;

Pt is on tab Atorvastatin 20mg /po/od

Tab glycometGP-2(glimiperide2mg+metformin500mg)od

TabmetXL25mg od

Tab enalapril5mg /po/od

Personal history;

Appetite; normal

Diet; mixed

Bowel and bladder movements; regular

Sleep; adequate

Addictions: chronic cigerrate smoker since 40 years , stopped after ptca

Alcoholic since 40 years

Family history; insignificant

General examination,;

The patient is conscious, coherent, cooperative and we'll oriented to time place person,moderately built and we'll nourished

Pallor ; absent

Icterus; absent

Cyanosis : absent

Clubbing : absent

Lymphadenopathy ; absent in

Edema : absent

Vitals; 

Temperature ; afebrile

Blood pressure;150/100 mmHg

Heart rate; 77bpm

Respiratory rate: 20 cpm

Spo2: 97%

GRBS; 157mg%

Systemic examination;

Cardiovascular system;

✓Inspection;

Position of trachea ;midline

No visible pulsations,no raised jvp

Precordial bulge : absent

Shape of chest; bilaterally symmetrical

Apex beat ; left 5th inter costal space1cm medial to mid clavicular line

✓Palpation; no tenderness,no local rise of temperature,all inspectory  findings are confirmed nopalpable thrills,parasternal heaves are palpable

✓Percussion ; Heart borders;

     Left border; 1.5cm internal to mid clavicular line

      Right border of heart; right of sternum at the level of 4th rib

      Upper border of heart; cannot be defined as dullness of heart tissue continues with dullness of big vessels

      Lower border of heart : cannot be defined ,as it lies in relation with the diaphragm and left lobe of liver below it

✓ Auscultation; 

S1,S2 heart sounds heared,no thrills and murmurs

Respiratory system ;

✓Inspection of upper respiratory tract;

Oral cavity ; normal

Nose; no DNS,polyp

Pharynx ; normal

✓Lower respiratory tract;

Position of trachea; midline

Position of Apex beat; left5ics 1cm medial to mid clavicular line

Symmetry of chest : symmetrical and elliptical

Movement of chest ; normal

 

✓Palpation ;

Position of trachea,apical pulse is confirmed

No tenderness over chest wall,no crepitation s,no palpable added sounds,no palpable pleural rub

* Vocal fremitus ; vibrations of chest are equal

✓Percussion;

Resonant note heared,no obliteration on traubes space

✓Auscultation;

 BAE-PRESENT

Normal vesicular breath sounds,no wheeze or no adventitious sounds

Per abdomen ;

Shape of abdomen ; scaphoid, soft, no tenderness

No palpable masses

Hernial orifices are normal

No free fluid,no bruits and engorged veins 

No organomegaly

Bowel sounds are heared

Central nervous system;

Level of consciousness: normal

Speech; slurred ,now speech was normal

No meningeal signs

Cranial nerves ;

1) olfactory nerve ; percieves smell on both sides

2) optic nerve : normal visual acuity

3) occlomotor nerve ; normal

4) trochlear nerve ;  normal

6) abducens nerve ; normal

(3,4,6 cranial nerves) ; ptosis,squint, nystagmus - absent.

* Ocular movements- present in upward,downward,temporal,nasal gaze

* Pupil- size- normal,shape- central

* Visual reflexes- direct, indirect- reacting to light

5) Trigeminal nerve ; cutaneous sensibility over skin and mucous membranes - present

✓ corneal reflex- present on both sides

✓ deviation of jaw on opening mouth- absent

7) facial nerve; normal

8) vestibuli cochlear nerve; normal

9) glossopharyngeal nerve; Taste sensation on posterior 1/3rd of tongue - present on both sides

✓palatal reflex- present on both sides

10)vagus nerve ; no history of regurgitation of fluids through nose

Palatal reflex- present

11) spinal accessory nerve ; normal

12) hypoglossal nerve ; normal

Motor system

Gait; normal

https://youtube.com/shorts/9RFhIDtqEPs?feature=share

https://youtube.com/shorts/9RFhIDtqEPs?feature=share

Power  U/L         L/L

   Right   4/5         4/5

    Left      5/5        5/5

Tone        U/L                    L/L

Right       increased        increased

Left          Normal             Normal 

Reflexes   Biceps triceps supinator knee ankle 

Right             2+             2+            2+      2+.   2+

Left                  2+             2+.          2+.   2+.   2+

Pupil : reacting to light

Conjunctival reflex +

Corneal reflex+

Sensory system ; normal

Investigations;

On 18/10/21;

RBS- 157

HbA1c- 6.9

Urea- 3.5

Creatinine-1.2

UA- 4

Calcium- 10

Phosphates- 3.6

Sodium-139

Potassium- 4.3

Chloride- 95

IB- 0.71

DB-0.20

AST; 21

ALT;19

TP; 6.9

A/G;0.82

ALP; 196

HB; 13.9

TLC; 6,700

NEUTROPHILS;54

LYMPHOCYTES;32

EOSINOPHILS;05

MONOCYTES;:09

BASOPHILS; 00

PLT; 2.63

19/10/21;

CUE

ECG;

MRI

Chest x ray

Provisional diagnosis; ?Acuteinfarct in left MCA territory

With Right UMN facial palsy

Right Hemiparesis (resolved)

K/c/o CAD,ptca ? 2DESto RCA

K/c/o Dm-2, hypertension

Treatment;

✓ Tab Enalipril 5mg/po/od

✓ Tabatorvastatin 40mg/po/pd

✓Tab ecosprin150mg/po/od

✓Tab glimeperide 2mg(1-x-x)+ metformin 500 mg (x-x-1)

✓Tab clopidogrel 75mg/po/HS(x-x-1 8pm)

✓syrup ascoril 10ml/po/ tid

✓ moniter BP,PR,RR

✓GRBS ministering 6th hrly

On 19/10/21

Diagnosis: small vessel ischemic changes with- TIA

Hypertensive microbleeds in basal ganglia

Vitals;

Temperature;98.7

BP: 130/100mmhg

PR;102bpm

RR: 24cpm

Cvs:S1,s2-+,no murmurs

Rs: normal vesicular breath sounds,decreased breath  sounds on right IAA

PA: soft,non tender

GRBS; 245 mg/dl

Spo2:96%@ RA

On 24/10/21;

He again got admitted on 24/10/21 due to right upper limb and lower limb weakness.which got relieved and get discharged on 25/10/21.