70 YEAR OLD MALE WITH RECURRENT CVA

FINAL PRACTICAL EXAM LONG CASE- 70 YEAR OLD MALE WITH RECURRENT CVA

General Medicine final practical exam- Long case

Hall ticket number: 1701006094

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.

A 70-year-old male has presented to the hospital on 06 June 2022 with the chief complaints of weakness of right upper and lower limbs,slurring of speech,difficulty in walking since 9 days

Timeline of events:

History of presenting illness:

He would wake up every day at about 6am, fresh up, have breakfast and do his daily chores like grazing the cattle till the afternoon. He would then have lunch and take a nap till evening. He then hung out with the neighbours, had dinner and rested for the day.

1st episode: Patient had been asymptomatic until 3 years ago when he suddenly developed weakness in his right upper and lower limbs, with no slurring of speech. He recovered completely after the treatment 

2nd episode: He suffered a second episode of abrupt onset weakening of the right upper and lower limbs a year ago, which was accompanied by drooping of the mouth and dribbling of saliva. He was treated for it and recovered completely 

3rd episode: He developed weakness of the right upper and lower limbs 9 days ago. He first was not able to walk then eat and then developed speech abnormality. He then went to an RMP and it was found that his blood pressure was high and advised the patient to go to the hospital. It was sudden in onset and gradually progressive 

History of past illness 

diagnosed with hypertension 10 months ago and has been using atenolol 25mg since.

not a known case of diabetes, asthma, epilepsy, or TB

Personal history 

married

normal appetite

takes vegetarian diet predominantly

bowel movements: regular

micturition is normal

no known allergies

addictions: alcohol abstinence since 5 years.

No similar complaints in the family.

General Physical Examination 

Done after taking informed consent 

Done in a well-lit room, in the presence of an attendant, with adequate exposure. The patient is conscious, incoherent, cooperative, well-nourished, and well-oriented to time, but not oriented to place and person.

No pallor icterus, Cyanosis, Koilonychia, Generalised Lymphadenopathy, Pedal oedema and clubbing

Slight muscle wasting in the right upper arm 

Vitals

Temperature - afebrile

Pulse rate- 70 bpm

BP- 140/80 mm Hg

Respiratory rate- 16/min

SYSTEMIC EXAMINATION:

1. CVS: S1 & S2 heard. No murmurs

2. Respiratory system

Bilateral air entry present

Normal vesicular breath sounds heard

3. Abdomen: Soft and non-tender. No organomegaly

4. CNS:

Dominance - Right-handed

4a) Higher mental functions

conscious and cooperative but incoherent

oriented to time, but not oriented to place and person.

memory- not able to recognize family members

Speech - only comprehension, no fluency, no repetition

4b)  Cranial nerve examination:

I- Olfactory nerve-  sense of smell present

II- Optic nerve- direct and indirect light reflex present

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis

V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.

VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.

VIII- Vestibulocochlear nerve- no hearing loss

IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised

XI- Accessory nerve- sternocleidomastoid contraction present

XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue

4c) Sensory system examination:

                                                   Right                                  Left  

crude touch                               present                              present

fine touch                                  absent                               present               

pain                                           absent                               present

vibration                                   absent                               present

temperature                              absent                               present

stereognosis-                            absent                               present 

2 pt discrimination-                 absent                               present

graphaesthesia-                        absent                               present 

 

                                                                  Right                                 Left  

   4d) Motor system examination

      4di) BULK:              U/L- arm           24.5 cm                           26 cm                                   

                                        -forearm           18 cm                              18 cm   

                                      

                                      L/L- thigh          44 cm                              44 cm

                                               - leg          28 cm                              28 cm

                  

      4dii) TONE:            U/L                    increased                       normal

                                      L/L                    increased                       normal

                                                      

                          

UPPER LIMBS

LOWER LIMBS

                                                                 Right                               Left  

      4diii) POWER:       U/L- hand           0/5                                   5/5

                                            - elbow         0/5                                   4/5

                                            - shoulder     0/5                                   5/5

                                      L/L- hip              0/5                                   4/5

                                            - knee            0/5                                   5/5   

                                            - ankle           0/5                                   4/5

LOWER LIMBS

UPPER LIMBS

                                                                Right                                  Left        

       4div) REFLEXES:    Biceps            +++                                    ++

                                         Triceps            +++                                   ++

                                         Supinator        +++                                   ++

                                         Knee               +++                                   ++

                                        Ankle              +++                                    ++

                                        Plantar          extension                          neutral

RIGHT BICEP

RIGHT KNEE 

BABINSKI

      4dv) COORDINATION:  Absent 

      4dvi) GAIT

No cerebellar signs 

No meningeal signs

INVESTIGATIONS:

CBP

Hemoglobin- 12.6 gm/dl (N)

PCV- 35.2 % (N)

• TLC- 8600/ cumm (N)
• RBC- 4.33 million/cumm (N)
• Platelets- 2.58 lakhs/ml (N)

Blood urea- 24 mg/dl (N)

Serum creatinine- 1.3 mg/dl (N)

Serum sodium- 136 mEq/L  (N)

Serum potassium- 3.7 mmol/l (N)

Serum chloride- 104 mEq/L (N)

LFT

Total bilirubin- 0.61 mg/dl  (N)

Direct bilirubin-  0.16 mg/dl (N)

SGPT- 11 (N)

SGOT- 13 (N)

ALP- 105 IU/L (N)

Albumin- 4 g/dl (N)

ECG

MRI

DRUGS: 

PROVISIONAL DIAGNOSIS:

Acute ischemic stroke causing right sided hemiplegia (left MCA territory)

Recurrent CVA 

TREATMENT:

Tab. Ecosporine 150mg

Tab. Clopidogrel 75 mg

Tab. Atorvas 40mg

Tab. Atenolol 25mg

Physiotherapy