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.

 

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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.  

  

A 70 year old Female with Neck - Muscle Stiffness and Loss of Speech

June 22, 2021

A 70yr old female came with complaints of neck muscle stiffness and unable to speak since 2 days

History of present illness:-

Patient was apprently asymptomatic 7years back then she developed pain in the right shoulder for which she was managed conservatively

5years ago she developed weakness and giddiness and on evaluation was diagnosed with HYPERTENSION (started with TAB.ATENOLOL 25mg which she stopped 2months ago and started taking TELMA-40 as prescribed by local medical practitioner since the BP was’nt under control).Also since 5yrs she developed pain in both lower limbs for which she was prescribed TAB.ACECLOFENAC AND TAB.PREDNISOLONE-5mg by an RMP and stopped taking these from 2months.

History of past illness:-

Not a known case of DM,TB,Bronchial Asthma

Personal history:-

1. She takes mixed diet and has decreased appetite
2. She has adequate sleep
3. Her bowel and bladder movements are normal and regular

Family history:-

No significant family history

Treatment History:

1. TAB. ATENOLOL 5mg
2. TELMA - 40 
3. TAB. ACECLOFENAC
4. TAB. PREDNISOLONE 5mg

General examination:-

1. She is conscious 
2. She has pallor
3. There is no icterus,cyanosis,clubbing 
4. Lymphadenopathy and pedal edema are also absent

Vitals:-

1. Temp :- afebrile
2. PR :- 105 Beats per minute
3. BP :- 130/80 mm of Hg
4. Respiratory rate :- 22 cycles per minute

Systemic examination:-

1. Per Abdomen Examination :

• Soft and tender 
• No mass and all quadrants moving equally with respiration

      

2. Cardiovascular system Examination :

• Cardiac sounds s1 and s2 heard normally
• No cardiac murmurs
• Thrills absent

      

3. Respiratory system Examination :

• Normal vesicular breath sounds heard
• No chest wall deformity 
• Trachea central
• Expansion is symmetrical
• Percussion note is resonant
• No wheeze or crackles heard.
• Vocal resonance normal and symmetrical

      

4. Central nervous system Examination :

• Conscious 
• Motor system reflexes normal
• Speech :- sluggish response
• Signs of meningeal irritation absent
• Cranial nerves are intact
• Rigidity seen(cogwheel type)
• Gait:-

Provisional diagnosis:-

1.  ? Hypocalcemic tetany
2. ?Parkinsons disease 

Investigations ordered:

1. ECG:

2. Complete Blood Picture (CBP):

3. Serum Creatinine:

4. Blood urea:

5. Serum Electrolytes:

6.MRI 

Diagnosis:-

Acute infarct in left frontal

Lobe

Treatment given:-

1. INJ.OPTINEURON 1amp in 100ml NS IV/OD
2. TAB. HIFENAC - MR PO/BD
3. TAB.SHELCAL 500mg PO/OD

Expected discharge summary:-

Chief complaints:-

Neck Muscle Stiffness and Loss of Speech

History of present illness:-

Patient was apprently asymptomatic 7years back then she developed pain in the right shoulder for which she was managed conservatively

5years ago she developed weakness and giddiness and on evaluation was diagnosed with HYPERTENSION (started with TAB.ATENOLOL 25mg which she stopped 2months ago and started taking TELMA-40 as prescribed by local medical practitioner since the BP was’nt under control).Also since 5yrs she developed pain in both lower limbs for which she was prescribed TAB.ACECLOFENAC AND TAB.PREDNISOLONE-5mg by an RMP and stopped taking these from 2months.

History of past illness:-

Not a known case of DM,TB,Bronchial Asthma

Personal history:-

1. She takes mixed diet and has decreased appetite
2. She has adequate sleep
3. Her bowel and bladder movements are normal and regular

Family history:-

No significant family history

General examination:-

1. She is conscious 
2. She has pallor
3. There is no icterus,cyanosis,clubbing 
4. Lymphadenopathy and pedal edema are also absent

Vitals:-

1. Temp :- afebrile
2. PR :- 105 Beats per minute
3. BP :- 130/80 mm of Hg
4. Respiratory rate :- 22 cycles per minute

Systemic examination:-

1. Per Abdomen Examination :

• Soft and tender 
• No mass and all quadrants moving equally with respiration

      

2. Cardiovascular system Examination :

• Cardiac sounds s1 and s2 heard normally
• No cardiac murmurs
• Thrills absent

      

3. Respiratory system Examination :

• Normal vesicular breath sounds heard
• No chest wall deformity 
• Trachea central
• Expansion is symmetrical
• Percussion note is resonant
• No wheeze or crackles heard.
• Vocal resonance normal and symmetrical

      

4. Central nervous system Examination :

• Conscious 
• Motor system reflexes normal
• Speech :- sluggish response
• Signs of meningeal irritation absent
• Cranial nerves are intact
• Rigidity seen(cogwheel type) in both upper limbs
  

Course in the hospital:-

Day 1:-

Treatment given:-  

1. Ing OPTINEURON lamp in 100 ml N/S IV/OD

                                  X - 1 - X

2. Tab MIFENAC - MR  PO/BD

                                  1 - X - 1

3. Tab PAN  40 mg PO/BD

                 1 - X - X

4. Tab FLUPERTINE PO/BD

                  1 - X - 1

5. oint OMNIGEL For L/A TID

                  ✓ - ✓ - ✓

6. Tab SHELCAL PO/OD

                  X - 1 - X

7. IFT Neck  Intermittent T cervical fraction

8. GRBS Monitoring

9. Tab Telma 40 mg PO/OD

10. Cervical collar

Day 2:-same treatment was continued

1.Tab UPRISE D3 60,000 IU weekly once

2.Tab Syndopa 110 mg BD were added.

Day 3 and day4 :-

Same treatment was continued

Day 5:-- syndopa 110mg BD stopped

TAB CLOPITAB 75mg PO/OD AND

TAB ECOSPIRIN-AV 75/20mg PO/OD were added

TAB HIFENAC-MR PO/BD 

TAB TELMA 40 PO/OD AND

TAB FLUPIRTINE PO/BD were with held

Rest of the treatment was same

Day 6:-:-same treatment as day 5

Day 7 ,8 and 9:-

TAB SYNDOPA 110mg BD added

1.TAB CLOPITAB 75mg PO/OD

2.TAB ECOSPIRIN -AV 75/20mg PO/OD

3.INJ OPTINEURON 1amp in 100ml NS/IV/OD

4.TAB PAN 40mg PO/OD

5. oint OMNIGEL For L/A TID

                  ✓ - ✓ - ✓

6. Tab SHELCAL PO/OD

                  X - 1 - X

7. Tab UPRISE D3 60,000 IU weekly once