42 yrs old male with tingling sensation in right limbs

This is an online Elog book to discuss our patient deidentified health data shared after taking his/ her guardians signed informed consent.

Here we discuss our individual patient problems through series of inputs from available Global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

This Elog also reflects my patient centered online learning portfolio.

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 a diagnosis and treatment plan.

Case: 

A 42 year old male resident of nalgonda, farmer by occupation came to OPD with cheif complaints of numbness, weakness in right upper and lower limbs.

HOPI :

Patient was apparently asymptomatic 20 years back. He had a history of trauma to head. 

PAST HISTORY :

 •Known case of hypertension  - 

•Not a known case of diabetes, asthma, TB, CHD

FAMILY HISTORY :

 

no significant family history

 PERSONAL HISTORY :

 

▪Diet-mixed

▪ Appetite-decreased

▪Bowel and bladder movements-Regular

▪Sleep - adequate

▪Habits- he was alcoholic and stopped since 8 months, and not a smoker

GENERAL EXAMINATION :

 ▪Patient is conscious , coherent and cooperative and well oriented to time, place and person, moderately built and moderately nourished.

Pallor- absent

Icterus- absent

Cyanosis- absent

Clubbing- absent

Lymphadenopathy- absent

Edema- absent

VITALS :

Temperature-98.6 F

Pulse rate-88 bpm

Respiratory rate-14 cpm

BP-160/100 mm Hg

Spo2-98%

GRBS-130 mg%

 

SYSTEMIC EXAMINATION: 

 

CNS examination

CARDIOVASCULAR SYSTEM- 

Inspection- 

The chest wall is bilaterally symmetrical.

No dilated veins, scars or sinuses are seen

Apical impulse or pulsations can be appreciated in sixth intercostal space 2cms lateral to mid clavicular line

Palpation-

Apical impulse is felt in the sixth intercostal space, 2 cm away from the midclavicular line

No parasternal heave or thrills are felt 

Percussion- 

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard

 RESPIRATORY SYSTEM-  

Inspection-

Chest is bilaterally symmetrical

The trachea is positioned centrally

Apical impulse is not appreciated 

Chest moves normally with respiration

No dilated veins, scars or sinuses are seen

Palpation- 

Trachea is felt in the midline 

Chest moves equally on both sides 

Apical impulse is felt in the sixth intercostal space 

Tactile vocal fremitus- appreciated 

Percussion-

The areas percussed include the supraclavicular, infraclavicular, mammary, axillary, infraaxillary, suprascapular, infrascapular areas.

They are all resonant.

Auscultation-

Normal vesicular breath sounds are heard

 • Abdomen- no tenderness seen, no palpable mass seen, not distended

Provisional diagnosis: 

CVA with acute ischemic stroke with infarct in the left thalamus with hypertension.

Plan of treatment: 

Tab. Aspirin 150mg PO/OD

Tab. Clopidogrel 75 mg

Tab. Atorvas 40 mg

Tab. Amlong 5mg

Tab. PAN 40mg 

Tab. Pregabalin 75mg

Tab. Telma 40/5

BP monitoring 4th hrly