long case

 This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed 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-blog also reflects my patient's centred 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 treatment plan.

A 65 year old male patient came to OPD with the cheif complaint of loss of speech since one day

History of present illness:

Patient was apparently asymptomatic one month ago then he had fever with chills not associated with nausea , vomiting,head ache,loose stools, giddiness. Necessary investigations were done and diagnosed with pulmonary Tuberculosis and deranged liver function test and anti tubercular drugs were prescribed and discharged.

Patient came for followup 2 days ago ,he was prescribed with new medication due to deranged liver function and renal function test.

Since last evening he had loss of speech (aphasia )

No weakness in upper and lower limb 

No H/o : vomiting, nausea, epilepsy, mouth deviation,head ache ,chest pain, sweating.

History of past illness:

K/c/o : pulmonary tuberculosis since 1 month 

N/k/c/o : diabetes, epilepsy,coronary artery disease 

Personal history: 

. Married 

. Occupation: farmer 

.Diet: mixed 

. Loss of appetite

.Constipation - pass stools once in 2-3 days

.Micturition: decreased urine, increased frequency 

. Allergies: nil 

. Addictions:- alcohol 90 ml per day since 30 years and 1 cigar for 2-3 days 

Family history:

No similar complaints in the family 

General examination:

Done after taking patients consent ,in a well lit room ,in the presence of attendant 

Patient is concious, incoherent,not coperative ;not well oriented to time, place and person; weakly built.

     . No pallor ,cyanosis, clubbing

      . Icterus - present

      .no odema and lymphadenopathy

Vitals :

Temperature: afebrile 

Pulse :72 bpm 

BP: 90/60 mm/hg 

Respiratory rate : 19cpm

Systemic examination: 

Cvs : S1 and S2 positive 

           No murmurs Heard

 CNS : speech - loss of speech 

            Behaviour - not oriented 

            Memory - not able to recognise family members

Motor examination:: Right.              Left 

Tone                           UL    LL          UL.    LL  

                                    Decrease. Decreased 

Power                         Decrease. Decreased 

Reflexes : Right.      Left 

Biceps -     2+.            2+

Triceps -. 2+.               2+ 

Knee -.      2+.               2+ 

Ankle -      2+                2+

Sensory examination:

Spinothalamic tract:: Right.     Left 

Pain                         Absent.      Absent          

Temperature.          Normal.     Normal

Posterior column ::

Fine touch               absent.     Absent              

Respiratory examination: 

Inspection: chest shape - symmetrical 

                     Chest expansion equal on both sides 

                    No kyphosis / scoliosis

  Palpation : trachea is in central position

  No localised rise in  temperature 

  No tenderness 

Percussion: dull notes on percussion

Auscultation: vesicular breath sounds Heard 

Investigations:

Vedio:

 https://youtu.be/vRc0_rsBWpI

Provisional Diagnosis: 

Pulmonary tuberculosis

Acute cerebro vascular accident 

 Treatment : 

Initial treatment -

Tab isoniazid 300mg  OD

Tab Rifampicin 300mg  BD

Tab Pyrazinamide 500mg TD

Tab Ethambutol 300mg TD

Present treatment -

Tab Ecosprin 75 mg 

Tab Neurobion forte