This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them
CASE PRESENTATION
May 31 admitted
A 55 YEAR MAN motor mechanic came to OPD with chief complaints difficult in swallowing and unable to speak since morning
HISTORY OF PRESENT ILLNESS
Pt was apparently normal till morning then he was unable to swallow milk and couldn't speak and drooling of saliva
No history of loss of consciousness , involuntary movements , no history of loss of sensation and weakness in extremities
No history of fever , shortness of breath, headache
He had history of wet cough 15 days back and he could not spit out the sputum
HISTORY OF PAST ILLNESS
Patient had similar compliants for 2 times ,1 st time giddiness and fall from the bike 3 years ago and diagnosed as denovo HTN and CT scan was done(was told to have clots in brain) for which he was on medication for 3 months
Had h/o ?memory disturbances 3 years back
Then with time gap of 2 months on a morning he noticed that he is unable to get up from bed due to weakness of left upper and lower limbs , also Slurring of speech and Deviation of mouth towards right side.
Acute ischemic CVA with left UL and LL hemiparesis(Late hyperacute infarct in Right PONS, chronic infarct in Right and Left Frontal and Right occipital)
HTN since 3 years
H/o Grade 1 hepatic encephalopathy (resolved) secondary to alcoholic liver disease with Pre renal AKI(resolved) 6 months back
H/o CVA 3 years back
TREATMENT HISTORY
K/C/O HTN since 3 yrs(on Tab. TELMA 40mg PO/OD)
No surgerical history
FAMILY HISTORY
No significant family history
PERSONAL HISTORY
Mixed diet
Normal appetite
Normal bowel and bladder habits
Addictions: drinks alcohol daily of 360 ml for 30 years and stopped 5 months back
Smokes daily of 1 pack for 30 years, stopped 5 months ago
No known allergies
GENERAL EXAMINATION
No Pallor,icterus , cyanosis, clubbing , lymphadenopathy, pedal edema
VITALS:
Temp:96.8 F
pulse rate:64 bpm
Bp:130/80 mm Hg
Resp rate:18 / min
GRBS : 126 mg%
SpO2 : 98
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM
Dominance -Right handed
Higher mental functions
Conscious
Oriented to time place and person
Memory -Immediate, recent and remote
Difficulty of speech present
difficulty in swallowing present
Motor system
Tone Right. Left
Upper limb Normal. Normal
Lower limb Normal. normal
power
Upper limb 4/5 4/5
Lower limb 4/5 4/5
Superficial reflxes
Corneal reflex normal on both sides
Conjunctival reflex normal on both sides
Plantar reflex
Deep tendon reflexes Right Left
Biceps ++ +++
Triceps. - ++
Supinator - +
Knee. Jerk ++ ++
Ankle jerk - +
RESPIRATORY SYSTEM
Inspection:
Shape of the chest : elliptical
B/L symmetrical ,
Both sides moving equally with respiration
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is equal on both side
Tactile vocal fremitus Normal
Auscultation:
. Normal vesicular breath sounds sounds heard
CARDIOVASCULAR SYSTEM
Inspection :
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
JVP is not raised
Palpation :
Apex beat can be palpable in 5th inter costal space medial to mid clavicular line
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
ABDOMINAL EXAMINATION
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible. pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
Auscultation- normal bowel sounds heard
PROVISIONAL DIAGNOSIS
4/6/23
COMPLAINTS
Fever spikes present + @ 12pm, 8pm, 11pm, 1am
Stools passed
ON EXAMINATION
Patient is conscious
Afebrile to touch
GCS: E4V1M6
Temp: 99F
PR- 70 bpm
RR- 24 cpm
BP- 110/70mmHg
Spo2- 96%
I/O: 2800/800 mL
CVS- S1 S2 present, no murmurs heard
RS-B/L air entry present, NVBS heard
PA- soft,NT, bowel sounds heard
CNS -Pupils: B/L NSRL
Tone is decreased in right upper and lower limbs, normal in left upper and lower limbs
Power: Right upper and lower limbs: 2/5
Left upper and lower limbs: 4/5
Reflexes:
Biceps: Rt: + Left: +++
Triceps: Rt: + Left: +++
Supinator: Rt: + Left: ++
Knee jerk: Rt: + Left: +++
Ankle: Rt: + Left: ++
Plantar: Rt: Extensor Left: Flexor
DIAGNOSIS
Recurrent CVA with Acute infarct in left hemipons with ? Bulbar palsy with ? Aspiration pneumonia with encephalomalacia in right hemipons b/l basal ganglia, Left thalamus, right occipital with Left hemiparesis 3 months back, ? Cardiac emboli and hypertension since 3 years
TREATMENT
1.IVF NS AND RL @30 ml/hr
2.RT Feeds: 200ml milk + 2 scoops protein powder 4th hourly,
100ml water 2nd hourly
4.Inj. NEOMOL 1gm IV/SOS
5.Tab. ECOSPIRIN + CLOPIDOGREL 150 + ATORVASTATIN 40 mg RT/HS
6.Tab. PCM 650 mg RT/SOS
7.Tepid sponging
8.Oral suctioning 4th HOURLY
9.Speech therapy and physiotherapy
10.Monitor vitals
5/6/23
COMPLAINTS
Fever spikes present + @ 5 pm on 4/6, 2 am on 5/6
Stools passed
ON EXAMINATION
Patient is conscious
Afebrile to touch
Temp: 98°F
PR- 93 bpm
RR- 33 cpm
BP- 140/80mmHg
Spo2- 96%
I/O: 3100/2700 mL
CVS- S1 S2 present, no murmurs heard
RS-B/L air entry present, Basal crepts present b/l IAA, ISA
PA- soft,NT, bowel sounds heard
CNS -Pupils: B/L NSRL
Tone is decreased in right upper limb, normal in lower limb, increased in left upper limb and normal in lower limb.
Power: Right upper limbs: 0/5, Lower limbs: 1/5
Left upper limbs: 3+/5, Lower limbs: 4/5
Reflexes:
Biceps: Rt: + Left: +++
Triceps: Rt: + Left: ++
Supinator: Rt: + Left: ++
Knee jerk: Rt: + Left: ++
Ankle: Rt: + Left: ++
Plantar: Rt: Extensor Left: Flexor
DIAGNOSIS
Recurrent CVA with Acute infarct in left hemipons with ? Bulbar palsy with ? Aspiration pneumonia with encephalomalacia in right hemipons b/l basal ganglia, Left thalamus, right occipital with Left hemiparesis 3 months back with Cardiac emboli secondary to ? CAD with New onset Right hemiparesis and hypertension since 3 years
TREATMENT
1.IVF NS AND RL @50 ml/hr
2.RT Feeds: 200ml milk + 2 scoops protein powder 4th hourly,
100ml water 2nd hourly
4.Inj. NEOMOL 1gm IV/SOS
5.Tab. ECOSPIRIN + CLOPIDOGREL 150 + ATORVASTATIN 40 mg RT/HS
6.Tab. PCM 650 mg RT/SOS
7.Tepid sponging
8.Oral suctioning 2nd HOURLY
9.Speech therapy,physiotherapy, early mobilization
10.Monitor vitals
6/6/23
COMPLAINTS
Fever spikes present
Stools passed
ON EXAMINATION
Patient is conscious
febrile to touch
Temp: 101.4°F
PR- 86 bpm
RR- 33 cpm
BP- 140/80mmHg
Spo2- 99% on O2 1-2 litres
CVS- S1 S2 present, no murmurs heard
RS-B/L air entry present, fine crepts present in left IAA, ISA
PA- soft,NT, bowel sounds heard
CNS -Pupils: B/L NSRL
Tone:
Tone is decreased in right upper limb and lower limb.Tone normal in left upper and lower limb.
Power:
Right upper limbs: 0/5, Lower limbs: 1/5
Left upper limbs: 3+/5, Lower limbs: 3+/5
Reflexes:
Biceps: Rt: + Left: ++
Triceps: Rt: + Left: ++
Supinator: Rt: - Left: +
Knee jerk: Rt: - Left: -
Ankle: Rt: - Left: -
Plantar: Rt: Extensor Left: Withdrawal
DIAGNOSIS
Recurrent CVA with Acute infarct in left hemipons with ? Bulbar palsy with ? Aspiration pneumonia with encephalomalacia in right hemipons b/l basal ganglia, Left thalamus, right occipital with Left hemiparesis 3 months back with Cardiac emboli secondary to ? CAD with New onset Right hemiparesis and hypertension since 3 years
TREATMENT
1.IVF NS AND RL @50 ml/hr
2.RT Feeds: 200ml milk + 2 scoops protein powder 4th hourly,
100ml water 2nd hourly
3.Inj. NEOMOL 1gm IV/TID
4.Tab. ECOSPIRIN + CLOPIDOGREL 150 + ATORVASTATIN 40 mg RT/HS
5.Tab. PCM 650 mg RT/SOS
6.Tepid sponging
7.Oral suctioning 2nd HOURLY
8.Speech therapy,physiotherapy, early mobilization
9.Monitor vitals
10.Frequent position change
7/6/23
Fever spikes present
Stools passed
ON EXAMINATION
Patient is conscious
febrile to touch
Temp: 103.4°F
PR- 102 bpm
RR- 26 cpm
BP- 130/80mmHg
Spo2- 95%
CVS- S1 S2 present, no murmurs heard
RS-B/L air entry present, fine crepts present in left IAA, ISA, mammary area
PA- soft,NT, bowel sounds heard
CNS -Pupils: B/L NSRL
Tone:
Tone is decreased in right upper limb and lower limb.Tone normal in left upper and lower limb.
Power:
Right upper limbs: 1/5, Lower limbs: 1/5
Left upper limbs: 3+/5, Lower limbs: 3+/5
Reflexes:
Biceps: Rt: + Left: ++
Triceps: Rt: + Left: ++
Supinator: Rt: - Left: -
Knee jerk: Rt: + Left: +
Ankle: Rt: + Left: ++
Plantar: Rt: Extensor Left: Flexor
DIAGNOSIS
Recurrent CVA with Acute infarct in left hemipons with ? Bulbar palsy with ? Aspiration pneumonia with encephalomalacia in right hemipons b/l basal ganglia, Left thalamus, right occipital with Left hemiparesis 3 months back with Cardiac emboli secondary to ? CAD with New onset Right hemiparesis and hypertension since 3 years
TREATMENT
1.IVF NS AND RL @50 ml/hr
2.RT Feeds: 200ml milk + 2 scoops protein powder 4th hourly,
100ml water 2nd hourly
3.Inj. NEOMOL 1gm IV/TID
4.Tab. ECOSPIRIN + CLOPIDOGREL 150 + ATORVASTATIN 40 mg RT/HS
5.Tab. PCM 650 mg RT/SOS
6.Tepid sponging
7.Oral suctioning 2nd HOURLY
8.Nebulization with mucomist 8th hourly
9.Speech therapy,physiotherapy, early mobilization
10.Monitor vitals
11.Frequent position change
Previous admission
Investigations:
Carotid doppler
Diagnosis:
Acute ischemic CVA with left UL and LL hemiparesis(Late hyperacute infarct in Right PONS, chronic infarct in Right and Left Frontal and Right occipital)
HTN since 3 years
Treatment:
Inj.. OPTINEURON in 100 ml NS IV/OD
Inj. THIAMINE 200 mg in 100ml NS IV BD
Tab. ECOSPIRIN-GOLD 20mg PO OD
Tab. PANTOP 40 mg PO/OD
Tab. TELMA 40 mg PO/OD
Physiotherapy of left UL&LL
