64 year old who is unable to talk since 1 day

Varsha bandaru
Roll no 07

This is 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 patients 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 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 diagnosis and treatment plan

CASE:

CHIEF COMPLAINTS:

Patient came to casuality with chief complaints of 
- unable to talk since 1 day 
- hiccups since 7 days
-  bowel and bladder incontinence, loss of appetite  since 3 days 
- loose stools 5 days back relieved on medication 
- fever 4 days back 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 7 days back , he then developed hiccups , loss of speech

-  5 days back he developed diarrhoea  5 episodes/ day , for one day which was relieved on medication 

-loss of appetite since 3 days , since one day he is unable to talk
 
- No H/O SOB , cough , palpitations
- No H/O loss of consciousness , giddiness , involuntary passage of urine and stools .

PAST HISTORY:

h/o panic attack one month back secondary to family issues 

- K/C/O DM2 since 2 yrs , on medication , 
-tab Metformin OD , tab Glimiperide OD

- Not a K/C/O HTN, TB, Asthma, epilepsy, CAD, CVD

PERSONAL HISTORY:

Appetite - lost

Diet - Mixed 

Sleep - adequate

Bowel and bladder movements - incontinence 

Addictions: Occasional alcoholic ( during functions ) , tobacco chewing occasionally 

Allergies : No allergies  

FAMILY HISTORY: Not significant

GENERAL EXAMINATION:

Patient is conscious ,incoherent , uncooperative
 Moderately Built and Moderately Nourished .

Pallor : present 
Icterus : absent 
Cyanosis: absent 
Clubbing : absent 
Lymphadenopathy : absent 
Edema : absent






His vitals :- 

Temp: Afebrile 
BP : 100 / 50 mmHg 
PR : 120 bpm 
RR : 16 cpm 
SPO2 : 98 % at RA
GRBS : 193 mg/dl 



SYSTEMIC EXAMINATION :

CNS examination :-
State of consciousness : conscious 
Speech : incoherent 
Kernigs sign :- positive

Sensory system :- 

Pain - Normal 
Touch- fine touch - normal
      crude touch - normal
Temp - normal
Vibration - normal
Joint position - normal

Cranial nerves : intact


CNS :-
                    Right. Left
Tone :- UL N. N
               LL. N. N

Power :- UL. 5/5. 5/5       
               LL 5/5 5/5 

Reflexes :-
Biceps + +
Tricep s + +
Supinator + +
Knee + +
Ankle. ++
Flexor. Plantar. Plantar 

Finger nose in coordination - no 
Heel knee in coordination - no

CVS : S1 S2 + ,no murmurs ,no thrills 

Respiratory System : decreased air entry on left side . Diffuse crepts on left side. Position of trachea - central.

Per abdominal examination:- 

Soft , non tender , no signs of organomegaly 

Investigations:- 
ECG 


CHEST XRAY PA VIEW:



USG abdomen : 



MRI BRAIN :


Hemogram


RBS:


LFT :


Serum creatinine :



Serum electrolytes : 



provisional diagnosis:- 

CVA: cerebro vascular accident .


Management:-
1) IVF 0.9 %NS IV @ 50 ml / hr 
2) Inj , 1 amp Optineuron in 500 ml NS IV /OD 
3) tab Ecosprin AV 75/10 RT / OD / HS
4) GRBS monitoring 6 th hrly 
5) Inj Thiamine 200 mg IV/BD in 100 ml NS 

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