A 63 year old male farmer by occupation who is a resident of Suryapet

 

This is an online e log book to discuss our patient de-identified health data shared after taking his/her/guardians signed informed consent. Here we discuss our individual patient problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence input.

This E blog also reflect my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including history , clinical finding , investigation and come up with diagnosis and treatment plan.

65 year old male farmer from Suryapet came with- 

Chief complaints of- 
1. Fever since 13 days 
2. Left upper limb paralysis since 10 days 
3. Decreased urine output since 10 days

History of presenting illness- 
The patient was apparently alright 13 days back then developed fever which resolved intermittently on administration of injections and medicines by the RMP. 10 days back, he developed dizziness and headache after which he developed weakness in the left wrist which progressed to the entire upper limb in the period of 1 day. He went to a Miryalguda hospital where he underwent investigations showing gall stones, renal infection and brain lesions. There was no improvement in his condition, he then came to our institution. He has no history of similar complaints in any other limb, loss of sensations, slurring of speech or head trauma. 

History of past illness- 
History of diabetes mellitus since 10 years 
History of hypertension with symptoms like dizziness and headache since 5-6 years. 
No history of TB, COPD, epilepsy. 

Treatment history- 
HTN- Telmisartan once 
DM- Metformin

Personal history- 
Patient's wife died 10 years back (fever and diarrhea) after which he developed DM, HTN
Daily routine- Wakes up at 6am, breakfast at 9 am, works from 9am-12pm, lunch at 1pm, dinner at 9pm. 
Diet- mixed
Appetite- decreased 
Bowel movements- normal 
Burning micturition present 
No allergies
No addictions

Family history- No similar complaints. 

General examination- 

I have taken the patient's consent and examined him in a well lit room- 
The patient is conscious, coherent, cooperative and oriented to time place and person. 
Build- moderate
Nourishment- adequate
Pallor -absent
Icterus - absent
Cyanosis- absent 
Koilnocycia-absent
Lymphadenopathy- absent
Edema- absent
VITALS
Blood pressure- left arm- 110/60mmHg, right arm- 120/60mmHg 
Pulse- 95 beats/min
Respiratory rate- 15 breaths/min
Temperature- afebrile


Central nervous system examination- 

The patient is right handed
Speech and memory are normal
Gait- 
https://youtu.be/B15As60zxws

Cranial nerves- 
1- Smell intact 
2- vision intact 
3, 4, 6- EOM full and free
5- Sensations of the face are intact
7- movements of the face are inact
8- Hearing and balance is intact
9, 10, 11- Gag reflex present, no uvula deviation, no difficulty in swallowing  
12- deviation of tongue absent
Motor examination 
REFLEXES 
Left upper limb tone-
left biceps reflex
left triceps reflex
Right upper limb tone-
right biceps reflex
right triceps reflex
Left lower limb tone and knee reflex-
Right lower limb tone and knee reflex-
Babinski sign - absent


Peripheral sensations are intact. 

Investigations- 
Brain MRI impression- 
• DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY WITH SMALL VESSEL ISCHAEMIC
CHANGES AS DESCRIBED.
• THERE ARE AREAS OF DIFFUSION RESTRICTION WITH CORRESPONDING LOW ADC MAP VALUES SEEN IN RIGHT HIGH FRONTAL AND RIGHT HIGH PARIETAL LOBES PREDOMINATELY
INVOLVING PREMOTOR, MOTOR AND SENSORY CORTEX AND IN RIGHT EXTERNAL CAPSULE REGION. THESE LESIONS ARE FLAIR HYPERINTENSE AND NOT BLOOMING ON SWI
- S/O SUBACUTE STAGE INFARCTS.
* CHRONIC INFARCT SEEN IN RIGHT CAPSULO-GANGLIONIC REGION.

Brain CT impression- 
SMALL HYPODENSE AREA IN THE RT CAPSULO GANGLIONIC REGION.
? INFARCT.


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