55 male with deviation of mouth

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I have been assigned this case to develop my competency in reading and comprehending clinical data, including the patient's history, clinical findings, and investigations, in order to come up with a diagnosis and treatment plan.

Case taken by Sangha Mithra

Case Summary:

Patient Information

55 YEARS OLD MALE CAME TO OPD WITH

CHIEF COMPLAINT:

C/O DEVIATION OF TH MOUTH TO THE LEFT SIDE SINCE 2 DAYS

C/O DIZZINESS SINCE 2 DAYS

C/O KNEE PAIN 2 DAYS

HISTORY OF PRESENT ILLNESS:

THE PATIENT WAS APPARENTLY ASYMPTOMATIC 2 DAYS AGO THEN HE DEVELOPED

DEVIATION OF THE MOUTH TO THE LEFT SIDE WHICH LASTED FOR 1 DAY AND BECAME NORMAL ON ITS OWN AFTER GETTING TREATED BY THE LOCAL MP AND THEN HE WAS BROUGHT TO THE HOSPITAL BY HIS ATTENDER TO THE OP AND GOT INVESTIGATED SINCE

1 DAY HE ALSO DEVELOPED SPASM OF THE RIGHT UPPER THIGH

WEAKNESS -VE TRAUMA -VE NO RESTRICTION OF MOVEMENTS INTERMITTENTLY HE DEVELOPED PAIN RADIATING TO THE RIGHT HIP TO TOE. PAIN AGGRAVATED ON WALKING.

NO DROOLING OF SALIVA, NO LOSS OF FOREHEAD WRINKLES.

PAST HISTORY.

KIC/O HT AND DM-II SINCE 12 YEARS AND USING MEDICATION 

SURGICAL HISTORY: LEFT BUTTOCK ABCESS DRAINAGE  

 

Family History:

- Not significant.

Personal History:

- Mixed diet, normal appetite, No addictions.

GENERAL EXAMINATION

PATIENT IS CONSIOUS, COHERENT AND COOPERATIVE NO PALLOR, ICTERUS.CLUBBING, CYNOSIS, LYMPADENOPATH

VITALS

BP: 130/80 MMHG

PR.86 BPM

RR: 18 CPM

SPO2:98%*

SYSTEMIC EXAMINATION;

Per abdomen:

Inspection:

 Shape of abdomen: flat

Umbilicus: Inverted and central

No visible pulsation, scars, swelling, sinuses, dilated veins .

Palpation: 

No local rise of temparature and tenderness 

Percussion: 

No fluid thrill, shifting dullness absent

Auscultation: 

Bowel sound heard 

CVS:

Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed. 

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:No local rise of temparature and no tendersness

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs.

CNS :

Mental state examination:

Appearance : hygiene maintained groomed 

Mood : fine ( she wants to go home or she wants her phone back )

Thought process : normal 

Perception : auditory and visual Hallucinations ( seeing snakes and someone calling her)

Orientated and conscious 

Memory: long term :good 

Short term : on 22nd June after 12am she wished her sister and slept after that She doesn’t remember anything till today morning she just remembered one or two events from yesterday 

Immediate: good

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : Visual acuity is normal

3rd,4th,6th : Pupillary reflexes present

 EOM full range of motion present        

 5th : Sensory intact

          Motor intact

 7th : normal.

8th : No abnormality noted.

9th,10th,11th,12th : normal.

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch Present 

Pain Present 

Temperature Present 

DORSAL COLUMN SENSATION:

Fine touch Present 

Vibration Present 

Proprioception Present 

CORTICAL SENSATION:

Two point discrimination Present 

Tactile localisation Present 

CEREBELLAR EXAMINATION:

 Finger nose test able to perform 

  Heel knee test able to perform

  Dysdiadochokinesia able to perform

Speech Normal 

Rhombergs test Absent

SIGNS OF MENINGEAL IRRITATION: 

Kernig's sign, brudzinski sign, neck rigidity absent

 

MOTOR EXAMINATION:

                                        Right Left

                                         UL LL UL LL

                       BULK: Normal Normal Normal Normal

                       TONE : Normal Normal Normal Normal

                    POWER : 5/5. 5/5. 5/5. 5/5

SUPERFICIAL REFLEXES:

CORNEAL present       

CONJUNCTIVAL present

DEEP TENDON REFLEXES normal 

REFLEXES: BICEPS TRICEPS SUPINATOR KNEE ANKLE

RIGHT +2 +2 +1 +2 +2

LEFT +2 +2 + 1 + 2 +2

ORTHO REFERAAL WAS DONE ON 12/8/2023 IV/O RIGHT KNEE JOINT TENDERNESS AND FULLNESS AND WAS EXAMINED BY ORTHOPEDICS DEPARTMENT.

Provisional diagnosis: ACUTE VA WITH ACUTE INFARCT IN THE BODY OF THE RIGHT CAUDATE AND RIGHT

CORONA RADIATA KNOWN CASE OF HYPERTENSION SINCE 12 YEARS AND KNOWN CASE OF DM I SINCE 11 YEARS WITH ACUTE ON CHRONIC GOUTY ARTHRITIS

Management :

Investigation

HEMOGRAM:

HB. 12GM/DL

TL COUNT: 14000 CELLS/CUMMN

PG

MCHG: 32.7%

RBC COUNT: 4.56 LAKHS/CUMM

PLATLET COUNT 2.40 LAKHS/CUMM

SEROLOGY: NEGATIVE

RENAL FUNCTION TEST, UREA 35 MG/DL CREATININE: 1.4 MD/DL SODIUM: 138 MEQ POTTASIUM: 4.4 MEQ/L CHLORIDE: 99 MEO/.

LIVER FUNCTION TEST:

T. BILRUBIN: 0.83 MG/DL

D. BILRUBIN: 1.26 MG/DL

AST: 11 ML

TOTAL PROTIENS: 6.1 GNOL

A/G RATIO: 0.87 GM/DL

ECG. NORMAL, REGULAR SINUS RHYTYM 

CHEST RAY: NORMAL

Treatment Given enter only Generic Name)

1. TAB. ECOSPRIN GOLD PO/SOS
2. TAB TELMISARTAN+ TAB. CLINIPINE+ TAB. METOPROLOL 40 MG/ 10MG/45MG POIOD
3. TAB. GLIMIPERIDE+ TAB. VOGLIBOND+ TAB.METFORMIN 2MG/0.2MG/500MG PO/OD

4, TAB. DOLO 650 MG PO/SOS

5. TAB. CEFTAZ-CL 200 MG PO/BD

6. TAB.HIFENAC-SPN PO/BD

7.TAB. GOUTNIL 0.5MG PO/BD

8. TAB. PANTOP 40 MG PO/OD

9. TAB. PREGABALIN 75 MG PO/OD

10. SYP LACTULOSE 10 ML PO/TID IN 1 GLASS OF WATER

Advice at Discharge

1. TAB. ECOSPRIN GOLD POISOS
2. TAB TELMISARTAN+ TAB. CLINIPINE+ TAB. METOPROLOL 40 MG