70 yr old male
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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. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
Patient came to the casualty in altered sensorium and was not oriented to place and had delayed response.
HOPI
PATIENT WAS APPARENTLY ALRIGHT 3HRS AGO, THEN HE HAD CHILLS AND RIGORS AND WAS IN ALTERED SENSORIUM SINCE THEN. HE WAS COMPLAINING OF NAUSEA AND RIGHT LOWER LIMB PAIN .
HISTORY OF PAST ILLNESS
K/C/O HTN SINCE 10 TO 15 YEARS , NOT USING ANTIHYPERTENSIVE SINCE 10 DAYS (AMLODIPINE 5MG)
K/C/O CVS 10 YEARS BACK- LEFT LOWER LIMB WEAKNESS, DEVIATION OF MOUTH PRESENT AND SLURRING OF SPEECH PRESENT.
N/K/C/O DM, TB, EPILEPSY.
Physical Examination:
Pallor:absent
Icterus: absent
cyanosis: absent
clubbing : absent
lymphadenopathy:absent
pedal edema: absent
SYSTEMIC EXAMINATION:
CNS:CNS examination:
Patient is cooperative.
Speech is normal.
Cranial nerves: intact
Motor system:
Tone:
Right Upperlimb - Normal
Left Upperlimb - Normal
Right Lowerlimb - Normal
Left Lowerlimb - Normal
Power:
Right Upperlimb - 4/5
Left Upperlimb - 5/5
Right lowerlimb - 4/5
Left lowerlimb - 0
Reflexes:
Right Left
Biceps + +
Triceps + +
Supinator 2+ 2+
Knee 2+ 2+
Ankle + +
CVS.
S1 and S2 are heard
No thrills
No murmurs
RESPIRATORY SYSTEM
INSPECTION:
Tracheal position is central
Symmetrical chest
PALPATION:.
All inspectory findings are confirmed by palpation
Trachea is central
Chest is symmetrical
Symmetrical expansion of chest.
PERCUSSION:
Resonant on percussion.
AUSCULTATION:
Breath sounds are normal.
PER ABDOMEN
Shape : scaphoid
Tenderness : Present
No palpable mass
Hernial orifices : Normal
No free fluid
No bruits
Bowel sounds : present.
2D ECHO REPORT:
SEVERE CONCENTRIC LVH+
MILD GLOBAL HYPOKINESIA.
MILD TR+ WITH PAH; TRIVIAL MR+/AR+
SCLEROTIC AV, NO AS/ MS.
EF=56%
GOOD LV SYSTOLIC FUNCTION
DIASTOLIC DYSFUNCTION+
IVC SIZE (0.6CMS) COLLAPSING.
MRI BRAIN.
IMPRESSION:EARLY SUBACUTE INTRA PARENCHYMAL HEMATOMA IN.RIGHT SUPERIOR PARIETAL LOBULE WITH SURROUNDING EDEMA.
ENCEPHALOMALACIA WITH GLIOSIS SEEN IN BILATERAL PUTAMEN(R>L) WITH PERIPHERAL BLOOMING FOCI- SUGGESTED OLD INFARCT WITH HEMORRHAGE.
MILD DIFFUSE CEREBRAL ATROPHY WITH SMALL VESSEL ISCHEMIC CHANGES WITH HYPERTENSIVE MICRO ANGIOPATHY CHANGES.
DIAGNOSIS: HAEMORRHAGIC STROKE(INTRA-PARENCHYMAL HEMATOMA IN RIGHT SUPERO- PARIETAL LOBULE)
ENCEPHALOMALACIA WITH GLIOSIS SEEN IN B/L PUTAMEN R>L) OLD INFARCT WITH HEMORRHAGE .
SMALL VESSEL ISCHAEMIC CHANGES WITH HYPERTENSIVE MICRO- ANGIOPATHY CHANGES.
K/C/O HTN,CVA
TREATMENT
1.INJ LABETOLOL 20 MG IV/STAT DILUTED IN 5 ML NS.
2. T.DOLO 650 MG PO/ TID.
3. INJ NEOMOL 1 GM IV/SOS.( IF TEMP> 101F
4.BP MONITORING - 2ND HRLY.
5.TAB ATORVAS 20 MG PO/ HS.
