85 YEAR OLD MALE WITH CVA

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Name: Sreshta J

Roll no: 48

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

An 85-year-old male has presented to the casualty on 23 September 2021 with the chief complaints of

• Weakness of left upper and lower limbs since 15 days
• Shortness of breath (SOB hereafter) since 15 days
• Dysphagia since 10 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 15 days ago then he developed weakness of the left upper and lower limbs. He went to a local doctor who treated him symptomatically. He was asked to return for a follow up 3 days ago and the doctor advised him to admit to the hospital. The attendants brought him to our tertiary care hospital instead for free treatment.

He also complained of giddiness 

WEAKNESS: 

• It was sudden in onset.
• he couldn't lift his left upper limb at all
• no h/o trauma or seizures.

SOB:

• he has grade 5 SOB

GIDDINESS:

• since 2 days
• relieved on sitting upright

PAST HISTORY :

• no similar complaints in the past.
• not a known case of diabetes, asthma, epilepsy, TB.
• diagnosed with hypertension 7 months ago and has been using medication since

PERSONAL HISTORY :

• married
• normal appetite
• takes mixed diet
• bowel movements: loose stools
• micturition is normal
• no known allergies
• addictions: none

No similar complaints in the family.

TREATMENT HISTORY:

Using medication for hypertension for 7 months now.

GENERAL EXAMINATION:

Done after obtaining consent, in a well-lit room, in the presence of an attendant, with adequate exposure. The patient is conscious, coherent, cooperative, well-nourished, well -oriented to time, place, person.

• No pallor icterus, Cyanosis, Koilonychia, Generalised Lymphadenopathy, Pedal oedema and clubbing
• Gynaecomastia is seen
• Muscle wasting is observed

VITALS at the time of admission:

• Temperature - afebrile
• Pulse rate- 100 bpm
• BP- 140/90 mm Hg
• Respiratory rate- 22/min
• Height- 170cm
• Weight- 38kg

SYSTEMIC EXAMINATION:

1. CVS: S1 & S2 heard

2. Respiratory system: COPD?

• SOB- grade 4 

3. Abdomen: Soft and non-tender

4. CNS:

• facial asymmetry is seen
• the mouth and tongue have deviated to the right side

                                                             Right                                  Left  

   4a) TONE:                  U/L              normal                           increased

                                       L/L               normal                           increased

   4b) POWER:              U/L             5/5                                   3/5

                                       L/L              5/5                                   5/5

   

   

    4c) REFLEXES:       Biceps             ++                                    +++

                                   Triceps             ++                                    +++

                               Supinator            ++                                    +++

                                      Knee             ++                                    +++

                                    Ankle              ++                                    +++

                                  Plantar           flexion(N)                       extension

Videos: 1. Exaggerated biceps reflex

2. Exaggerated triceps reflex

INVESTIGATIONS:

CBP

CXR

ECG

Lipid Profile

Serum Electrolytes

Serum Creatinine

Blood urea-

PROVISIONAL DIAGNOSIS:

? CVA secondary to left-sided hemiparesis