A CASE OF ACUTE CVA PRESENTED IN SUMMER 2023

NOTE: 

  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent. 

  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.

  • This E-log also reflects my patient's centered online learning portfolio.

I have 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 providing treatment best to our skills and wisdom.

A 70 years old male farmer by occupation presented to the casualty with complaints of weakness of right upper and lower limb with inability to talk since yesterday (8/9/23)

Date of Admission: 08/09/23

CHIEF COMPLAINTS 

Weakness of right upper and lower limb since 4 days( 8/9)

Inability to talk since 4 days(8/9)

HISTORY OF PRESENTING ILLNESS

 Patient was apparently asymptomatic till last Friday afternoon (8/9/23). He had his lunch around 12pm after which he called his grandson and after which his speech got slurred . He observed marked weakness in right upper and lower limbs and was not able to get up from the bed. Family members thought it to be simple weakness due to old age so they ignored it. They used diapers for urine and stool. Next morning (9/9/23) weakness persists and he was not able to talk so they came to our hospital. 

 Weakness was sudden in onset non progressive. No aggravating or relieving factor.

Slurring of speech was sudden and progressed to inability to talk. 

H/o Drooling of saliva 

H/o hiccups 

No h/o deviation of mouth 

No h/o involuntary movements, bladder and bowel incontinence 

No h/o loss of consciousness 

No h/o breathlessness , cough, fever, palpitation, reduced urine output and vomiting. 

HISTORY OF PAST ILLNESS 

Patient had similar complaints 1 year back for which he took medication for 3 months and as symptoms got improved he left the medicine. 

K/c/o CVA (left hemiparesis)  1year back 

K/c/o HTN since 2 years

N/k/c/o Diabetes, epilepsy, TB, Asthma 

DRUG HISTORY 

tablet amlodipine 5mg 

tablet atenolol 50mg po/od

PERSONAL HISTORY

➤Occupation: Farmer

➤Patient is married .

➤Patient takes mixed diet and has a normal appetite.

➤Bowel and bladder movements are normal 

➤No known allergies .

➤Addictions - Consumes alcohol regularly  

General Examination


➤Pallor : not seen 

➤Icterus : not seen 

➤Cyanosis : not seen 

➤Clubbing : not seen 

➤Lymphadenopathy : not seen 

➤Edema : not seen 


VITALS 


➤Temperature : 98.2℉

➤PR : 74 beats per minute

➤BP : 160/90 mm of Hg

➤RR : 20 cycles per minute

➤SpO2 : 98% in room air

➤Blood Sugar (random) : 269mg/dl

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent 

➤Speech :  Impaired

➤No signs of meningeal irritation 


Motor system


Tone:-


Rt UL - Hyper

Rt LL-Hyper


Lt LL-Hypo

Lt LL- Hyper

Power:-


Rt UL - 0/5      Lt UL-3/5


Rt LL - 0/5       Lt LL-3/5


Reflexes: 


RIGHT 



Biceps: ++



Triceps: ++


Supinator: ++


Knee: ++


Ankle: ++


Plantar:  Extensor

LEFT

Biceps: +++



Triceps: ++


Supinator: ++


Knee: +++


Ankle: ++

Plantar:  Extensor



Involuntary movements - absent


Fasciculations - absent


sensory text cannot be elicited

Cerebellum - 

Finger nose test , dysdiadochokinesia, Rhomberg test could not elicited.

Autonomic nervous system - normal

• Meningeal sign  

Neck stiffeness -absent 

Brudzinski sign -absent

Kernigs sign - absent


CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent.,

➤No cardiac murmurs


RESPIRATORY SYSTEM


➤Normal vesicular breath sounds heard.

➤Bilateral air entry present

➤Trachea is in midline.

ABDOMINAL EXAMINATION

INSPECTION

➤Shape - Scaphoid

➤Equal movements in all the quadrants.

➤No visible pulsation, dilated veins and localized swellings.

PALPATION

➤Liver , spleen not palpable.

➤No tenderness 


PROVISIONAL DIAGNOSIS : RIGHT HEMIPARESIS 

 RECURRENT CVA WITH K/C/O HYPERTENSION SiNCE 2 YEARS 


INVESTIGATIONS : 

 

1. Haemogram

                            9/09/23             10/09/23

 Hb ;                    13.4                    13.3

TLC :                  11,000                 14,300

Platelet count :     3.18                     3.1

PCV :                    38.4                    38.3


3. Serum Creatinine  - 1.3


4. Serum Na+ - 131


5. Serum Chloride - 98


6. Serum Calcium - 1.14


7. Blood urea - 41


8. RBS - 210 

TREATMENT


1) Ryle's tube feeding - 2nd hourly water and 4th hourly milk

2) Ecosporin - AV 75 mg/hr PO OD

3) Atenolol 50mg

4)Physiotherapy 






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