This 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.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.
This is a case of a 70 year male who came with a complaint of
1. Fall 10 days back
2. History of fever since 5 days
3. Inability to speak since 1 day
HISTORY OF PRESENTING ILLNESS:
The patient was apparently alright 6 months ago. Then he developed a habit of speaking to himself. He imagined he's speaking to his son and daughter who do not live with him.
This happens once or twice a month.
One such instance when he was speaking to himself he ended up falling down when leaning and fracturing his right femur. He was treated at a local hospital and apparently he was placed in a cast for 3 weeks. The cast was removed and he was able to walk.
Again 10 days back he slipped while walking according to his attender. He fractured his left femur and was treated in a local hospital. He was given traction and was put on bed rest.
5 days back he developed a swelling on his lower back about 5 x 5 cm which was discharging pus.
He also developed fever associated with chills and body pains since 5 days which is insidious in onset. Not associated with rigor, nausea, vomiting, pain abdomen, burning micturation
Since 2 days he is not able to speak properly. He speaks in short phrases which do not make sense and difficulty in finding words. He is able to understand spoken conversation.
Past history
No history of previous hospitalisations.
Not a known case of diabetes, hypertension
Personal history
Daily routine:
Patient lives with his wife in an old age home. Before that he was a daily wage labourer. He gets up in the morning and freshens up. Then he has breakfast in the old age home and then converses with his wife. He takes a morning nap and then has lunch. After that he interacts with his fellow senior citizens in the old age home. He has dinner at 8 pm and then he sleeps at 9 pm.
Diet mixed
Appetite normal
Sleep adequate -
Bowel and bladder regular
Habits Consumes alcohol occasionally during family events
Family history
Not significant
CLINICAL EXAMINATION
Patient is conscious but not coherent and cooperative. He oriented to time and person but not place
Pallor absent
Icterus absent
Clubbing absent
Cyanosis absent
Lymphadenopathy absent
Edema absent
Vitals
BP 141/90
PR 95 BPM
Temp 99°F on 28-12-22
RR 23 cpm
CNS EXAMINATION
HIGHER MENTAL FUNCTIONS:
Conscious, not oriented to time place and person.
Speech : slurred, able to pronounce vowels but not consonants
Behavior : is aggitated and irritable
Memory : not able to assess
Intelligence : not able to assess
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
3rd,4th,6th : Patient was not cooperative to assess
5th : sensory intact
7th : inability to blow cheeks
8th : No abnormality noted.
9th,10th : palatal movements present and equal.
11th,12th : normal.
MOTOR EXAMINATION: Right Left
UL LL UL LL
BULK decreased decreased decreased decreased
TONE hypertonia hypertonia normal normal
POWER 0/5 - 2/5 -
Decorticate posturing
SUPERFICIAL REFLEXES:
CORNEAL present present
CONJUNCTIVAL present present
DEEP TENDON REFLEXES:
R L
BICEPS 3 2
TRICEPS 3 2
SUPINATOR 1 2
KNEE - -
ANKLE - -
SENSORY EXAMINATION:
SPINOTHALAMIC SENSATION:
Crude touch diminished on right upper limb
pain felt on right upper limb
Supraorbital pressure felt
Sternal rub pain felt
DORSAL COLUMN SENSATION:
Fine touch not able to perceive on right upper and lower limb
CEREBELLAR EXAMINATION:
Finger nose test unable to perform with right hand
Dysdiadochokinesia not able to perform
Nystagmus not seen
SIGNS OF MENINGEAL IRRITATION: absent
GAIT:
unable to assess due to traction applied
CVS
Cardiovascular System :
Inspection :
Precordium :
No precordial bulges.
No engorged veins.
No scar/sinus.
JVP
Other findings :
Patient is using accessory muscles to breathe.
Apex Beat : appears to be at the 5th Intercostal Space 1cm lateral to midclavicular line.
Chest wall Defects : None.
PALPATION :
Inspectory finding of Apical beat correlated on Palpation, can be localized 1cm lateral to the midclavicular line in the 5th Intercostal Space.
AUSCULTATION :
S1 ,S2 heard.
RS BAE, no added breath sounds
ABDOMEN soft and non tender
PROVISIONAL DIAGNOSIS
CVA - Right sided hemiplegia with altered sensorium
Broca's like aphasia
UMN type facial palsy(?)
Infarct in left internal capsule due to thrombus in MCA artery
INVESTIGATIONS
TREATMENT
Inj Meropenam 500 mg IV/BD
Inj .clindamycin 600 mg IV/BD
Inj pan 40 mg IV/OD
Inj neomol 1gm IV/OD
Ecospirin -AV 75/10 RT/HS
INJ .optineuron 1 amp in 100 ml NS IV/OD
Tab dolo 650 mg TID
IV Fluids NS , RL 2 units @ 75 ml / hr
Vital monitoring 6 th hrly
Temperature monitoring 4 th ly
Strict I/O charting
Skin traction with weights 2.5 kgs to B/L lower limbs
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