Bhavana Chenna: September 2021

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Bhavana Chenna,

9th semester,

Roll No - 20

Case Discussion :

I have been given this case to solve in an order to 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.

A 53 year old Female patient came to the Hospital with :

Chief Complaints :

* Fever since 10 days

* Weakness of Left Upper and Lower Limbs since 2 days

* Slurring of Speech since 2 days

History of Present Illness :

* Patient was apparently asymptomatic 10 days back and came to the OPD with the Complaints of Fever since 10 days which is of Low Grade, Insidious in onset, Intermittent and is not associated with chills and rigors for which she went to a local RMP and took medications, after which her fever was subsided.

On 16/08/2021:

* After having dinner, She went to sleep and

complained of having pain in the left upper and left lower limb and slurring of speech at 1 pm.

(As noticed by the attenders).

On 17/08/2021:

* After waking up early in the Morning, she was alright and went to her son's house. In view of above complaints which she had at night, Her son took her to a local RMP and there when she was asked to walk, she developed weakness of Left Upper Limb and Left Lower Limb and was not able to lift her Left UL & LL.

* She even didn't speak & didn't recognise the people around her and was Unresponsive but she was in the conscious state. She was found to be have high BP (Systolic 200 mm of Hg) and was managed conservatively for it with TAB ENALAPRIL

5 mg.

* She was referred to a hospital in Hyderabad, where she had undergone CT Brain which shows AGE RELATED CEREBRAL ATROPHY and MILD TO MODERATE LEFT MAXILLARY AND ETHMOIDAL SINUSITIS. From there she was referred to our Hospital on 18/08/2021 at 2 pm.

History of Past Illness :

* Patient was well built 30 years back and after which her daily routine was changed as she was devoted to God and used to eat once a day, due to which she started losing weight gradually since then.

* Due to some family issues, She fell ill 10 years back and went to local hospital for checkup and was found to have TYPE 2 DM. She is taking medications regularly since then.

* 10 years Ago, while doing her daily routine work, she suddenly had syncopal attack with Weakness, Tingling sensation and Numbness

of lower limbs and was taken to local Hospital, and found to have low serum potassium levels and was adviced to use SYP POTKLOR. (she

used to take it whenever she has weakness of limbs).

* From then, she had 5 to 6 similar attacks till now for which she was managed conservatively in a local hospital. And every time she was advised to use SYP POTKLOR as her K+ levels were found be low.

* She even use to have Generalised body pains since 10 yrs occasionally from then, and used to take pain killers (?unknown) as prescribed by local Doctor. Pains used to subside after taking medications.

* She is not a known case of Hypertension, CAD, Asthama, Thyroid disorders and Epilepsy.

Family History :

No History of Diabetes mellitus, Hypertension, Asthma, Tuberculosis, Epilepsy, Thyroid disease and CAD in the Family.

Personal History :

Diet: Vegetarian

Appetite: Normal

Sleep: Adequate

Bowels & Bladder movements: Regular

Addictions: Absent

Physical Examination :

A. General Examination :

* Patient is conscious and unresponsive and is unable to sit comfortably on the bed.

* She is not so well oriented to time, place and person.

* She is severely Malnourished.

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Lymphadenopathy: Absent

Edema: Absent

Vitals:

Temperature: Afebrile

Pulse rate: 90 BPM

Respiratory rate: 20 CPM

Blood pressure: 130/80 mm of Hg

SPO2: 95%

Random Blood sugar: 526 mg%

B. Systemic Examination :

Cardiovascular system :-

* S1, S2 heard , No murmurs

Respiratory system :-

* Position of trachea:- central

* Bilateral air entry +

Per Abdomen :-

* Abdomen is soft, Nondistended and non tender.

* No organomegaly.

* No palpable mass or fluid present

Central Nervous system :-

Patient is conscious.

1. Higher Mental Functions:-

▪️Appearance & behaviour - Thin built , Disoriented (at admission)

▪️ Level of consciousness - Conscious

▪️ Cognitive functions :

* Glasgow Coma Scale - E4V2M6

* Memory & attention - Not elicited

* Speech & language - No response

* MMSE - Not elicited

2. Cranial Nerve Examination :-

▪️Olfactory - Not elicited

▪️Optic :

* Visual acuity, Visual field, Colour vision - not elicited

▪️ Oculomotor, Trochlear and Abducent :

* Pupils are reactive and normal

* No ptosis & nystagmus

▪️Trigeminal :

* Sensory - not elicited

* Motor - not elicited

* Corneal reflex - present

* Conjunctival reflex - present

▪️ Facial nerve :

* Motor - Nasolabial fold lost on left side and No deviation of mouth

* Sensory - Taste not elicited

* Secretomotor - Moistness of eye and tongue is Normal and Buccal mucosa is Normal.

▪️ Vestibulocochlear - Rinne's & Weber's Test not elicited

▪️ Glossopharyngeal and Vagus :

* Gag Reflex - Not elicited

* Uvula - Centrally placed

▪️ Spinal accessory :

* Trapezieus - Not elicited

* Sternocleidomastoid - Not elicited

▪️ Hypoglossal :

* No Deviation of Tongue

* No wasting and No Fibrillations.

3. Motor System:-

▪️ Attitude & position - Patient in supine position with left lower leg externally rotated

▪️ Bulk - Normal

▪️ TONE :

Right Left

Upper Limb - Normal Hypotonia

Lower Limb - Normal Hypotonia

▪️ POWER :

Right Left

Upper Limb - 5/5 2/5

Lower Limb - 5/5 2/5

▪️ REFLEXES :

Superficial Right Left

* Corneal - +2 +2

* Conjunctival - +2 +2

* Abdominal - +2 +2

Deep Right Left

* Biceps : + Absent

* Triceps : + Absent

* Supinator : + Absent

* Knee jerk : + +

* Ankle jerk : + Absent

* Plantar : flexor mute

4. Sensory System:-

* Not elicited

* Pain present in all 4 limbs

5. Cerebellum:-

* Nystagmus - Absent

* Intentional tremors - Absent

* Pendular knee jerk - Absent

* Coordination test - Not done

* Gait - Can't be elicited

6. No Meningeal signs

Investigations :

On 18th August,2021-

Chest X - Ray :-

Complete Blood Picture :-

Complete Urine Examination :-

HBsAg - RAPID :-

HIV 1/2 Rapid Test :-

Serum Creatinine :-

Random Blood Sugar :-

Blood Urea :-

Glycated Haemoglobin :-

Liver Function Test :-

Urine for Ketone Bodies :-

SARS - COV - 2 Qualitative PCR :

Serum Electrolytes :-

Serum Calcium :-

USG Abdomen :-

Renal Mass in the Right Upper Pole of Kidney ?

Adrenal Mass ?

Electrocardiogram :-

2D Echo :-

On 19th August,2021-

Lipid Profile :-

Serum Electrolytes :-

Urinary Electrolytes :-

Erythrocyte Sedimentation Rate :-