A 70 year old with loss of speech

29/12/2022

G meghana 

Intern

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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 diagnosis and treatment plan.

This is a case of a 70 year male who came with a complaint of 

1. Fall 10 days back

2. History of fever since 5 days

3. Inability to speak since 1 day

HISTORY OF PRESENTING ILLNESS:

The patient was apparently alright 6 months ago. Then he developed a habit of speaking to himself. He imagined he's speaking to his son and daughter who do not live with him.

This happens once or twice a month.

One such instance when he was speaking to himself he ended up falling down when leaning and fracturing his right femur. He was treated at a local hospital and apparently he was placed in a cast for 3 weeks. The cast was removed and he was able to walk.

Again 10 days back he slipped while walking according to his attendor. He fractured his left femur and was treated in a local hospital. He was given traction and was put on bed rest.

5 days back he developed a swelling on his lower back about 5 x 5 cm which was discharging pus.

He also developed fever associated with chills and body pains since 5 days which is insidious in onset. Not associated with rigor, nausea, vomiting, pain abdomen, burning micturation

Since 2 days he is not able to speak properly. He speaks in short phrases which do not make sense and has difficulty in understanding conversation and finding words.

Past history

No history of previous hospitalisations. 

Not a known case of diabetes, hypertension

Personal history

Daily routine:

Patient lives with his wife in an old age home. Before that he was a daily wage labourer. He gets up in the morning and freshens up. Then he has breakfast in the old age home and then converses with his wife. He takes a morning nap and then has lunch. After that he interacts with his fellow senior citizens in the old age home. He has dinner at 8 pm and then he sleeps at 9 pm.

Diet- mixed

Appetite -normal

Sleep; adequate

Bowel and bladder- regular

Habits -Consumes alcohol occasionally during family events 

Family history

Not significant

CLINICAL EXAMINATION 

Patient is conscious but not coherent and cooperative. He oriented to time and person but not place

Pallor absent

Icterus absent

Clubbing absent

Cyanosis absent

Lymphadenopathy absent

Edema absent

Vitals

BP 141/90

PR 75 BPM

Temp 99°F on 28-12-22

RR 23 cpm

CNS EXAMINATION 

HIGHER MENTAL FUNCTIONS:

Conscious, not oriented to time place and person.

Speech : slurred, able to pronounce vowels but not consonants

Behavior : is aggitated and irritable 

Memory : not able to assess a

Intelligence : not able to assess

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : visual acuity is normal          

3rd,4th,6th : Patient was not cooperative to assess

5th : sensory intact                    

7th :no abnormality noted

8th : No abnormality noted.

9th,10th : palatal movements present and equal.

11th,12th : normal.

MOTOR EXAMINATION: Right Left

                                           UL LL UL LL

   BULK decreased decreased decreased decreased

   TONE hypotonia hypotonia normal normal

   POWER 0/5 - 2/5 -

   SUPERFICIAL REFLEXES:

    

    CORNEAL present present

   CONJUNCTIVAL present present

  

   DEEP TENDON REFLEXES:

   BICEPS 3 2                  

   TRICEPS 3 2                        

   SUPINATOR 1 2                

   KNEE - -                         

   ANKLE - -         

    

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch diminished on right upper limb

pain diminished on right upper limb

DORSAL COLUMN SENSATION:

Fine touch not able to perceive on right upper and lower limb

CORTICAL SENSATION:

Two point discrimination unable to discrimate on right upper and lower limb

Tactile localisation unable to do on right upper and lower limb

CEREBELLAR EXAMINATION:

  Finger nose test unable to perform with right hand

  Dysdiadochokinesia not able to perform

  Nystagmus not seen

SIGNS OF MENINGEAL IRRITATION: absent

GAIT:

  unable to stand without support

 unsteady with a tendency to fall

unable to perform tandem walking.

CVS S1 S2 heard, no murmurs

RS BAE, no added breath sounds

ABDOMEN soft and non tender

INVESTIGATIONS:-

provisional diagnosis :-

CVA - Acute infarcts in right posterior occipital region, right cuneus, right superior & inferior parietal lobule, left insular cortex - Embolic nature.

Treatment

Inj Meropenam 1gm IV/OD

Inj .clindamycin 600 mg IV/BD 

Inj pan 40 mg IV/OD 

Inj neomol  1gm IV/OD 

Ecospirin -AV 75/10 RT/HS

INJ .optineuron  1 amp in 100 ml NS IV/OD 

Tab dolo 650 mg TID 

IV Fluids NS , RL 2 units  @ 75 ml / hr 

Vital monitoring 6 th hrly

Temperature monitoring 4 th ly 

Strict I/O charting 

On 30/12/22:- 

Inj Meropenam 500 mg IV/BD

Inj .clindamycin 600 mg IV/BD 

Inj pan 40 mg IV/OD 

Inj neomol 1gm IV/OD 

Ecospirin -AV 75/10 RT/HS

INJ .optineuron 1 amp in 100 ml NS IV/OD 

Tab dolo 650 mg TID 

IV Fluids NS , RL 2 units @ 75 ml / hr 

Vital monitoring 6 th hrly

Temperature monitoring 4 th ly 

Strict I/O charting 

Skin traction with weights 2.5 kgs to B/L lower limbs 

On 31/12/2022

Inj Meropenam 500 mg IV/BD

Inj .clindamycin 600 mg IV/BD 

Inj pan 40 mg IV/OD 

Inj neomol 1gm IV/OD 

Ecospirin -AV 75/10 RT/HS

INJ .optineuron 1 amp in 100 ml NS IV/OD 

Tab dolo 650 mg TID 

IV Fluids NS , RL 2 units @ 75 ml / hr 

Vital monitoring 6 th hrly

Temperature monitoring 4 th ly 

Strict I/O charting 

Skin traction with weights 2.5 kgs to B/L lower limbs

On 1/1/2023:-

Inj Meropenam 500 mg IV/BD

Inj .clindamycin 600 mg IV/BD 

Inj pan 40 mg IV/OD 

Inj neomol 1gm IV/OD 

Ecospirin -AV 75/10 RT/HS

INJ .optineuron 1 amp in 100 ml NS IV/OD 

Tab dolo 650 mg TID 

IV Fluids NS , RL 2 units @ 75 ml / hr 

Vital monitoring 6 th hrly

Temperature monitoring 4 th ly 

Strict I/O charting 

Skin traction with weights 2.5 kgs to B/L lower limbs

2/2/2023:-

ICU

Bed 2 

Unit 3 

Day 5

Dr.Nikitha (SR )

Dr.Vamshi Krishna ( PG 3 )

Dr. Nishitha ( PG 2 ) 

Dr.Govardhini Reddy ( PG 1 )

Dr. Meghana ( intern )

Dr. Tejarshini ( intern)

S - 1 fever spike at 8 am 

O :- 

pt is conscious, coherent,cooperative 

BP : 120/80 mm hg 

PR: 90 bpm

RR : 16 cpm

I/O :- 2150/1300 ml

GRBS :-  104 mg/dl

CVS :- S1 , S2 heard , no murmurs 

RS:- BAE + 

PA : soft , non tender 

 GCS : E4V4M6

A : 

Altered sensorium ( resolved ) secondary to AIS 

CVA-AIS  involving right PCA and MCA territory, left insular Cortex? , Cardioembolic B/L closed 

AKI ( prerenal ) ( resolved ) 

P

 :

-IV Fluids 0.9 %NS , RL 2 units @ 75 ml / hr 

-Inj pan 40 mg IV/OD 

-Tab. Ecospirin -AV 75/10 PO/HS

-INJ .optineuron 1 amp in 100 ml NS IV/OD 

-Tab dolo 650 mg TID 

-Vital monitoring 6 th hrly

-Temperature monitoring 4 th ly 

-Strict I/O charting 

-Skin traction with weights 2.5 kgs to B/L lower limbs

Patient was discharged on 2/1/2023