65 year old male with CVA

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.

Following is the view of my case 

CASE PRESENTATION 

A 65 old male presented to opd with the chief complaints of

          -- slurring of speech   

      --  difficulty in walking 

         --  weakness of left upper limb since  yesterday 

         -- complain of pedal edema .

History of present illness 

Patient was apparently asymptomatic 6 months back then he had h/o  loose stools 6 to 7 episodes daily ,low quantity , yellow colour

No association with pain abdomen,no mucus in stool 

No blood in stool 

History of fever 2 episodes in the past 6 months 

No history of nausea vomiting 

No history decreased appetite 

History of past illness 

K/c/o Hypertension from 7 years telma H prescribed for hepertension

N/K/C/O diabetes mellitus ,epilepsy,tuberculosis 

H/o trauma 1 month back (slip and fell in bathroom)

H/o surgery 18 years back for hernia

H/o acute ischemic stroke

personal history 

Married 

Diet : mixed 

Decreased appetite 

Bowel irregular 

Micturition normal 

No known allergies 

Addictions : habit of alcohol consumption daily 

No similar complaints in the family 

General examination 

Done after obtaining consent , in a well lit room ,in the presence of an attendent ,with adequate exposure 

The patient is conscious incoherent and incoperative ,poorly nourished 

Pallor is present 

 No icterus,cyanosis ,koilonychia 

History of pedal edema 

Pedal edema is non pitting type and extending upto feet

Vitals 

BP 130/70 mmhg

PR 80bpm

RR 16 cycles per min

Temperature : afebrile 


SYSTEMIC EXAMINATION

Respiratory system 

Inspection 

Chest is normal bilaterlly symmetrical 

Position of trachea is normal

No scars , sinuses or visible pulsations 

palpation 

All inspectory findings are confirmed

No local rise in temperature 

No tenderness

 Cvs

Inspection : 

No visible engorged veins, scars or sinuses on chest 

Palpation :S1 amd S2 are heard

No thrills or murmers 

Percussion : heart borders are appreciated 

Auscultation : 

No cardiac murmers are heard

Abdomen 

Inspection : 

Umbilicus : central inverted

Soft and non tender

Palpation :

No local rise in temperature

No organomegaly

Free fluid no 

No bruits 

Liver and spleen are not palpable

Percussion : 

Resonant


CNS 

TONE : UL          LL

             N            N

            hypo        N 

Higher mental functions

- Conscious +

- Oriented to  time+,place+ and person+

- Memory - intact

- Speech - slurred

MOTOR SYSTEM:

 

TONE        UL.    N.   Left hypotonia

                    LL.    N.    N

POWER

a) neck muscles

b) UL

•shoulder

•Elbow

•Wrist               0/5

• Small muxles & hand

      Hand grip

 c) LL

•Hip

. Knee

Ankle

Small musles

(d) Trunk muscle

 REFLEXES.

a)

A       superficial.

corneal.     ++

Conjunctival. ++

Pharyngeal   ++

Palatal.   ++

Sensory SYSTEM

Test


I-SPINOTHALAMIC       Right        Left


1. Crude touch.   ++

2. Pain++

3. Temperature++

II    POSTERIOR COLUMN

1.fine Touch++

2. Vibration++

3. Position sense++

III CORTICAL

1. Two point discrimination++

2. Tactile localisation++

3 Graphaesthesia+

Cranial nerve examination

     1olfactory sense - normal

     2- visual acuity present,

                                    R    L


           Direct reflex    +.   +                 


        Indirect reflex    +    +

   3,4,6 - no ptosis Or nystagmus

   5- corneal reflex present

  7-  deviation of mouth, no loss of nasolabial     folds, forehead wrinkling present

  8- Normal 

 9,10- position of uvula is central

 11- sternocleidomastoid contraction present

 12- deviation of tongue 

Investigations 


ultrasound 


ecg 

19/01/2023

20/01/23

Fever chart 
MRI 
Hyper acute infarct in right frontal lobe and adjacent corona radiata

Clinical images 



Provisional diagnosis : 

Cerebro vascular accident with hyperacute infarts and hypertension 

Treatment 

Tab clopidogrl 75 mg OD 

Tab ecospirin 75 mg OD 

Tab atarvostat 20 mg OD 

Tab  telma

Tab telmesartan 40 mg OD 







                 








































         








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