PATIENT CAME WITH C/O INABILITY TO SPEAK, DEVIATION OF ANGLE OF MOUTH, DROOLING OF SALIVA

 Case History and Clinical Findings:-

 PATIENT CAME WITH C/O INABILITY TO SPEAK SINCE 8 HOURS, DEVIATION OF ANGLE OF MOUTH SINCE 8 HOURS, DROOLING OF SALIVA SINCE 8 HOURS 

HISTORY OF PRESENT ILLNESS:-

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS AGO, HE THEN HAD RTA BY FALL FROM BIKE AND SUSTAINED RIGHT ACETABULAR FRACTURE AND WAS ON CONSERVATIVE MANAGEMENT FROM THEN BY TRACTION AND WEIGHT BEARING. TODAY MORNING AT 8AM PATIENT HAD SUDDEN ONSET SLURRING OF SPEECH 8 HOURS AGO WITH DEVIATIN OF ANGLE OF MOUTH TO RIGHT AND DROOLING OF SALIVA AND FOOD CONTENT FROM THE MOUTH. N/H/O INVOLUNTARY MOVEMENTS, LOSS OF CONCIUSNESS, HEADACHE, GIDDINESS, VOMITING. N/H/O NECK RIGIDITY, WEAKNESS OF UL OR LL PAST HISTORY K/C/O HTN SINCE 5 YEARS , DM SINCE 2 YEARS CVA 5 YRS AGO.

 GENERAL EXAMINATION:-

PATIENT IS MODERATELY BUILT AND NOURISHED .

 NO SIGNS OF ICTERUS , CYANOSIS , CLUBBING ,LYMPHADENOPATHY, EDEMA.

 VITALS :

 TEMPERATURE : 98.6 F

 PR - 86 BPM 

BP - 130/90 MMHG

 RR - 23 CPM 

SPO2 - 98% ON RA 

GRBS - 190 MG/DL 

CVS- S1S2+ NO MURMURS 

R/S- BAE+ NVBS 

P/A- SOFT, NT 

CNSGCS- E4V1M6

 POWER         RT     LT 

                  UL 5/5 5/5

                  LL 4/5 5/5

 TONE           RT     LT

                 UL N     N

                 LL N      N

 REFLEXES RT    LT 

 BICEPS         3+   1+ 

TRICEPS       2+    1+ 

SUPINATOR 2+    1+ 

KNEE             3+   1+ 

ANKLE          1+   1+ 

PLANTAR FLXN ETXN SENSATIONS OVER FACE PRESENT

 DEVIATION OF ANGLE OF MOUTH TO RIGHT

 DECREASED FROWNING ON LEFT SIDE 

 UNABLE TO PROTRUDE TONGUE APHASIA

 COURSE IN HOSPITAL:-

PATIENT PRESENTED WITH THE ABOVE MENTIONED COMPLAINTS AND WAS EVALUATED CLINICALLY AND WITH THE APPROPRIATE INVESTIGATIONS . PATIENT WAS DIAGNOSED TO HAVE RECURRENT CVA WITH ACUTE INFARCT IN RIGHT INSULAR REGION. RYLES TUBE FEEDINGS WERE GIVEN AND WAS STARTED ON DUAL ANTIPLATELETS. ORTHO OPINION WAS TAKEN I/V/O RIGHT ACETABULAR FRACTURE AND ADVISED CONSERVATIVE MANAGEMENT WITH SKIN TRACTION AND WEIGHT BEARING. NEUROLOGIST OPINION WAS TAKEN AND WAS DIAGNOSED AS ? OPERCULAR SYNDROME. POOR PROGNOIS REGARDING THE IMPROVEMENT IN PATIENT CONDITION HAS BEEN EXPLAINED. PATIENT WAS HEMODYNAMICALLY STABLE AT THE TIME OF DISCHARGE. RYLES TUBE CARE HAS BEEN EXPLAINED AND RISK OF ASPIRATION EXPLIAINED TO PATIENT ATTENDERS.

provisional Diagnosis:-

 RECURRENT CVA WITH ACUTE INFARCT IN RIGHT INSULAR REGION

 ?OPERCULAR SYNDROME WITH RIGHT ACETBULAR FRACTURE WITH K/C/OHTN SINCE 5 YEAR, 

TYPE II DM SINCE 2 YEARS

 H/O CVA 5 YEARS AGO WITH RIGHT HEMIPARESIS

Investigation:-

 HB- 13.5 MG/DL

 PCV- 40.4

 TLC- 13,600

 RBC- 4.95

 FBS- 162 

HBA1C- 7.4 

2D ECHO ON 10/5/23:-

CONCENTRIC LVH, NO RWMA NO AS/MS. SCLEROTIC AV NO MR/AR. TRIVIAL TR GOOD LV SYSTOLIC FUNCTION. DIASTOLIC DYSFUNCTION + NO PAH

 Treatment Given:-

 IVF NS@ 75ML/HR RT FEEDS- 200ML

 MILK 4TH HRLY 200 ML WATER 2ND HRLY 

TAB. ASPRIN+ CLOPIDOGREL 75/75MG RT/OD

 TAB. ATORVASTATIN 20MG PO/HS

 TAB ULTRACET 1/2 TAB PO/QID 

GRBS 7 POINT PROFILE INJ. HAI SC TID 

AS PER GRBS NEB. WITH DUOLIN 6TH HRLY

 NEB. WITH BUDECORT 8TH HRLY 

TAB. CLINIDIPINE 10MG PO/BD

 MONITOR VITALS AND INFORM SOS

 


Comments

Post a Comment

Popular posts from this blog

My experience with general cellular pathology in a case based blended learning ecosystem’s CBBLE

  WARM REGARDS, I'm shivani tunia, a passionate medical student from India. Welcome to my blog, where I share captivating real-life cases that have not only deepened my understanding of history taking and clinical examination but also enhanced my patient interaction skills and overall patient care approach. These cases have been invaluable in shaping my medical journey, and I'm excited to share them with you. Together, let's delve into the captivating world of patient care, where every interaction holds the potential for learning, growth, and making a positive impact on the lives of those we serve. Thank you for joining me on this incredible journey! CBBLE PAJR PARTICIPATORY LEARNING ACTION RESEARCH DISCLAIMER  NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONL...
Read more

70 YEAR OLD FEMALE WITH FEVER AND LEFT SIDED PAIN

Image
 T.shivani   MBBS 9th semester Roll no:06 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 . Following is the view of my case.. 70 yr old female with fever and left sided chest pain . January 11, 2022 A 70 year old female came to casuality on 05-01-2022 with...
Read more

A 55 YEAR OLD PATIENT WITH FEVER CHEST PAIN AND LOSS OF APPETITE

Image
January 01, 2023   A 55 years old patient presented with fever, chest pain and loss of appetite This is an 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 patient's 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 the comment box"  - 55  year old male,  -farmer by occupation,   -came to Medicine OPD with complaints of :-  —>  Chief Complaints: -( Fever since 13 days , chest pain since 10 days, and loss of appetite since 10 days ) -History of present illness:- —>Patient was apparently asymptomatic 8 months ago then he developed fever , cough, shortness of breath on exertion fever is of h...
Read more