60 yr old female , labourer by occupation

This is an 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 patient's 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 the comment box is welcome.”


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 : 

A 60 yr old female , labourer by occupation, presented to casulity with c/o left upper limb, lower limb weakness since 4 days which was sudden in onset.


History of present illness : 
Pt was apparently asymptomatic 4 days back.Later suddenly she was unable to move her left hand which was associated with slurring of speech with deviation of mouth to right side progressing to left lower limb and was made to stay at home hoping it would improve .As it wasn't improving pt was taken to hospital  where an mri was done and was referred to our hospital .
At the time of admission pt was conscious and confused and unable to speak 
Unable to open the mouth fully 
Unable to stand or walk with support
No history of blurring of vision 
No history of difficulty in hearing 
No loss of facial sensations
No h/o double vision
No h/ drooling of saliva

Past history : 
No similar complaints in the past 
No history of any surgeries or blood transfusions
Not a K/C/O hypertension, diabetes,asthma epilepsy ,CVA ,CAD


Personal history: 
Diet- mixed 
Appetite - normal
Sleep- adequate
B&B - normal, regular
Occassional alcoholic, non smoker

General examination:

Pt is conscious
Moderately built and moderately nourished 
No signs Pallor,Icterus, cyanosis, clubbing, lymphedenopathy,edema are  present








Vitals:
Afebrile
Bp- 160/100 mmhg
Pr- 68bpm
Rr-20cpm
Spo2- 98% on room air
Grbs-116%
 

Systemic examination

CVS: S1, s2 heard
Rs- BAE+ NVBS+
P/A : soft, non tender
CNS:
conscious, confused
Slurred  speech
Power- R L
    UL 5/5  3/5
    LL 5/5 4/5
Hand  grip 100% 20%
Tone
UL          N      N
LL    increased   increased
Reflexes
Biceps  2+     3+
Triceps 2+     3+
Knee     2+     3+
Ankle     +       2+ 
Babinski sign  + - 

Provisional diagnosis:

 Acute ischemic stroke( CVA) - left Upper limb and lower limb hemiparesis with slurring of speech 

Investigations : 
 

Hemogram:

Hb- 13.1 
TC - 7400 
RBC - 4.95
PCV - 39.5
PLC - 3.30 


CUE : 
Alb - Trace 
Sugar - Nil

RBS : 

RBS - 91 

Urea : 

Urea - 48 

Creatinine

Creatinine - 0.8


 Serum electrolytes : 
Na - 140
K - 4.4
Cl - 97

FLP : 

TC - 258
TGL - 120 
HDL - 61 
LDL - 85 
VLDL - 24 


 
Chest xray : 



2D ECHO : 

ECG : 



Treatment : 

On day 1 of admission : 

Pt C/C/C
Speech improved
Afebrile
Bp- 130/90 mmhg
Pr- 78bpm
Rr-20cpm
Spo2- 98% on room air
Grbs-116%
 

CVS: S1, s2 heard
Rs- BAE+ NVBS+
P/A : soft, non tender
CNS:
conscious, confused
Slurred speech
Power- R L
    UL 5/5 3/5
    LL 5/5 4/5
Hand grip 100% 20%
Tone
UL N N
LL increased increased
Reflexes
Biceps 2+ 3+
Triceps 2+ 3+
Knee 2+ 3+
Ankle + 2+ 
Babinski sign extension Flexion


1) TAB .ECOSPRIN 250 mg PO/OD
2)TAB.CLOPITAB 75 MG PO/OD 
3)TAB.ATORVOSTATIN 40 MG PO/HS 
4)PHYSIOTHERAPY OF UPPER LIMB AND LOWER LIMB 
5) MONITOR BP 

On day 2 of admission : 
 
Pt C/C/C
Complains of headache ,slurring of speech improved 
Afebrile
Bp- 160/100 mmhg
Pr- 76bpm
Rr-20cpm
Spo2- 98% on room air
Grbs-116%
 

CVS: S1, s2 heard
Rs- BAE+ NVBS+
P/A : soft, non tender

CNS:
conscious, confused
Slurred speech
Power- R L
    UL 5/5 3/5
    LL 5/5 4/5
Hand grip 100% 20%
Tone
UL N N
LL increased increased
Reflexes
Biceps 2+ 3+
Triceps 2+ 3+
Knee 2+ 3+
Ankle + 2+ 
Babinski sign extension Flexion


1) TAB .ECOSPRIN 250 mg PO/OD
2)TAB.CLOPITAB 75 MG PO/OD 
3)TAB.ATORVOSTATIN 40 MG PO/HS 
4)PHYSIOTHERAPY OF UPPER LIMB AND LOWER LIMB 
5) TAB.AMLONG 5 MG PO/OD 
6)MONITOR BP 

On day 3 of admission : 

1) TAB .ECOSPRIN 250 mg PO/OD
2)TAB.CLOPITAB 75 MG PO/OD 
3)TAB.ATORVOSTATIN 40 MG PO/HS 
4)PHYSIOTHERAPY OF UPPER LIMB AND LOWER LIMB 
5) TAB.AMLONG 5 MG PO/OD 
6)MONITOR BP 


Discharge summary : 

A 60 yr old female , labourer by occupation, presented to casulity with c/o left upper limb, lower limb weakness since 4 days which was sudden in onset.


History of present illness : 
Pt was apparently asymptomatic 4 days back.Later suddenly she was unable to move her left hand which was associated with slurring of speech with deviation of mouth to right side progressing to left lower limb and was made to stay at home hoping it would improve .As it wasn't improving pt was taken to hospital  where an mri was done and was referred to our hospital .
At the time of admission pt was conscious and confused and unable to speak 
Unable to open the mouth fully 
Unable to stand or walk with support
No history of blurring of vision 
No history of difficulty in hearing 
No loss of facial sensations
No h/o double vision
No h/ drooling of saliva

Past history : 
No similar complaints in the past 
No history of any surgeries or blood transfusions
Not a K/C/O hypertension, diabetes,asthma epilepsy ,CVA ,CAD


Personal history: 
Diet- mixed 
Appetite - normal
Sleep- adequate
B&B - normal, regular
Occassional alcoholic, non smoker

General examination:

Pt is conscious
Moderately built and moderately nourished 
No signs Pallor,Icterus, cyanosis, clubbing, lymphedenopathy,edema are  present





 


 



Vitals:
Afebrile
Bp- 160/100 mmhg
Pr- 68bpm
Rr-20cpm
Spo2- 98% on room air
Grbs-116%
 

Systemic examination

CVS: S1, s2 heard
Rs- BAE+ NVBS+
P/A : soft, non tender
CNS:
conscious, confused
Slurred  speech
Power- R L
    UL 5/5  3/5
    LL 5/5 4/5
Hand  grip 100% 20%
Tone
UL          N      N
LL    increased   increased
Reflexes
Biceps  2+     3+
Triceps 2+     3+
Knee     2+     3+
Ankle     +       2+ 
Babinski sign  + - 

Provisional diagnosis:

 Acute ischemic stroke( CVA) - left Upper limb and lower limb hemiparesis with slurring of speech 

Investigations : 
 

Hemogram:

Hb- 13.1 
TC - 7400 
RBC - 4.95
PCV - 39.5
PLC - 3.30 

 


CUE : 
Alb - Trace 
Sugar - Nil

 

RBS : 

RBS - 91 

 

Urea : 

Urea - 48 

 

Creatinine

Creatinine - 0.8

 


 Serum electrolytes : 
Na - 140
K - 4.4
Cl - 97

 

FLP : 

TC - 258
TGL - 120 
HDL - 61 
LDL - 85 
VLDL - 24 


 
 
Chest xray : 

 



2D ECHO : 

 

ECG : 



Treatment : 

On day 1 of admission : 

Pt C/C/C
Speech improved
Afebrile
Bp- 130/90 mmhg
Pr- 78bpm
Rr-20cpm
Spo2- 98% on room air
Grbs-116%
 

CVS: S1, s2 heard
Rs- BAE+ NVBS+
P/A : soft, non tender
CNS:
conscious, confused
Slurred speech
Power- R L
    UL 5/5 3/5
    LL 5/5 4/5
Hand grip 100% 20%
Tone
UL N N
LL increased increased
Reflexes
Biceps 2+ 3+
Triceps 2+ 3+
Knee 2+ 3+
Ankle + 2+ 
Babinski sign extension Flexion


1) TAB .ECOSPRIN 250 mg PO/OD
2)TAB.CLOPITAB 75 MG PO/OD 
3)TAB.ATORVOSTATIN 40 MG PO/HS 
4)PHYSIOTHERAPY OF UPPER LIMB AND LOWER LIMB 
5) MONITOR BP 

On day 2 of admission : 
 
Pt C/C/C
Complains of headache ,slurring of speech improved 
Afebrile
Bp- 160/100 mmhg
Pr- 76bpm
Rr-20cpm
Spo2- 98% on room air
Grbs-116%
 

CVS: S1, s2 heard
Rs- BAE+ NVBS+
P/A : soft, non tender

CNS:
conscious, confused
Slurred speech
Power- R L
    UL 5/5 3/5
    LL 5/5 4/5
Hand grip 100% 20%
Tone
UL N N
LL increased increased
Reflexes
Biceps 2+ 3+
Triceps 2+ 3+
Knee 2+ 3+
Ankle + 2+ 
Babinski sign extension Flexion


1) TAB .ECOSPRIN 250 mg PO/OD
2)TAB.CLOPITAB 75 MG PO/OD 
3)TAB.ATORVOSTATIN 40 MG PO/HS 
4)PHYSIOTHERAPY OF UPPER LIMB AND LOWER LIMB 
5) TAB.AMLONG 5 MG PO/OD 
6)MONITOR BP 

On day 3 of admission : 

1) TAB .ECOSPRIN 250 mg PO/OD
2)TAB.CLOPITAB 75 MG PO/OD 
3)TAB.ATORVOSTATIN 40 MG PO/HS 
4)PHYSIOTHERAPY OF UPPER LIMB AND LOWER LIMB 
5) TAB.AMLONG 5 MG PO/OD 
6)MONITOR BP 


Discharge summary : 






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