(CASE BASED OSCE)73F Fever, drowsy, mute, refusing food, bed wetting 5/10/2023

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 patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.





This E blog also reflects 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 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.



Case

73 YEAR OLD FEMALE RESIDENT RAMANNAPET WEAVER BY OCCUPATION CAME TO CASUALITY IN DROWSY STATE AROUSABLE SINCE 5/10/23 AFTERNOON 


HOPI: PT WAS APPARENTLY ASSYMPTOMATUC TILL 5/10 23 MORNING THEN SHE DEVELOPED FEVER A/W COLD 

THEN FROM EVENING SHE STARTED BEHAVING DIFFERENTLY (REFUSAL TO EAT FOOD ; UNABLE TO SPEAK PROPERLT ) WITH URINARY INCONTINANCE

NO H/O VOMITINGS ; LOOSE STOOLS ; PAIN ABDOMEN ; BURNING MICTURITION; COUGH ; COLD


PAST H/O: K/C/ O HTN SINCE 15 YEARS (ON TAB.TELMA 40 MG + METOPROLOL 25MG PO/OD)

SHE WAS DIAGNOSED WITH HYPERTENSION AS A PART OF ROUTINE EXAMINATION WHEN SHE CONSULTED A DOCTOR WHEN SHE HAD FEVER 15 YEARS BACK

N/K/C/O DM; CAD; CVA; TB;ASTHMA.

HYSTERECTOMISED 1 YEAR BACK I/V/O PROLAPSE


PERSONAL H/0:

APPETITE- DECREASED SINCE 5/10/2023 EVENING 

MIXED DIET

BOWEL- REGULAR

BLADDER - INCONTINENCE SINCE 5/10/2023 EVENING

NO ADDICTIONS 


FAMILY H/O :NOT SIGNIFICANT 


MENSTRUAL H/O :

HYSTERECTOMISED 1 YEAR AGO


GENERAL PHYSICAL EXAMINATION:

PATIENT IS IN DROWSY STATE ON 5/10/23

NO SIGNS OF PALLOR; ICTERUS; CYANOSIS; CLUBBING; PEDAL EDEMA; LYMPHADENOPATHY 


VITALS

BP- 200/110 MM OF HG

PR - 110BPM

GRBS - 109MG/DL

RR-14/CPM


SYSTEMIC EXAMINATION 

CVS - S1; S2 HEARD ,NO MURMURS 

RS- BAE+,NVBS +

PER ABDOMEN- 

OBESE ABDOMEN


SOFT; NONTENDER; NO ORGANOMEGALY


CNS - 

LEVEL OF CONSCIOUSNESS - 

DROWSY AROUSABLE

SPEECH - SLURRED

NO NECK STIFFNESS 

KERNIGS SIGN- ABSENT

CRANIAL NERVES- COULDNOT BE ELICITED

MOTOR SYSTEM- RT LT

                          TONE UL N N

                                    LL N N

SENSORY SYTEM - COULNOT BE ELICITED

GLASGOW SCALE- E3V5M5 12/15

POWER RT LT

                                 UL 3/5 3/5

                                  LL 3/5 3/5 

REFLEXES BICEPS ; TRICEPS ; KNEE REFLEX OF RL - PRESENT


CEREBELLAR SIGNS- COULNOT BE ELEICITED

GAIT - NORMAL

CNS EXAMINATION 



1. HIGHER MENTAL FUNCTIONS:

a. Conscious-drowsy but arousable


Speech - slurred


d. Memory – immediate-retention and recall, recent and remote are present


e. No delusions, hallucinations


f. No Emotional lability



2.CRANIAL NERVE -                                Right               left


                                                            Normal         Normal 


3.MOTOR SYSTEM-



      Bulk


 Inspection                                         Normal         Normal


 Palpation                                           Normal         Normal 


Measurement



Upper limb – 10cm below acromion  ( same on both )


Lower limb 18 cm below tibial tubercle  (same on both)



Tone



Upperlimb                                           Normal         Normal


Lowerlimb                                           Normal        Normal



Power



a. Neck muscles                                Good             Good



b. Upper limbs     


                    


i) Shoulder                                           5/5                5/5


Flexion-Extension                           


Lateral Rotation-Medial Rotation     5/5                5/5


Abduction -Adduction                        5/5                 5/5


ii) Elbow


Flexion-Extension                               5/5                5/5


iii) Wrist


Dorsi flexion-Palmar flexion              5/5                5/5


Abduction-Adduction                         5/5                 5/5


Pronation-Supination                         5/5                 5/5


iv) small muscles of hand               Good              Good 


v) Hand grip                                      Good              Good




c. Lower limbs


i) Hip                                                     5/5                5/5


Flexion-Extension


Abduction-Adduction                          5/5                5/5


Lateral Rotation-Medial Rotation       5/5                5/5


ii) Knee


Flexion-Extension                                 5/5                5/5


iii) Ankle


Dorsi flexion-Plantar flexion                5/5               5/5


Inversion-Eversion                                5/5               5/5


iv) Small muscles of foot                   Good           Good





REFLEXES 



SUPERFICIAL REFLEXES 


A.Corneal reflex                                 Present    Present


B.Conjunctival reflex                         Present    Present   


C.Abdominal reflex                           Present     Present   


D.Plantar reflex                                  Present    Present   



DEEP REFLEXES 


A.Biceps                                             +2                +2


B.Triceps                                           +2                 +2


C.Supinator                                       +2                  +2


D.Knee jerk                                        +2                  +2


E.Ankle jerk                                       +2                  +2



SENSORY SYSTEM                          Normal       Normal


CEREBELLAR SIGNS                        Absent       Absent


SIGNS OF MENINGEAL IRRITATION     Absent







2D ECHO REPORT

1.TACHYCARDIA

2.VPC+

3.NO RWMA ;MILD LVH+(1.22CM)

4. MILD AR+ ;MILD TR+ ;NO MR

5.SCLEROTIC AV ; NO MS /AS , IAS - INTACT

6.EF-62% RVSP= 35+10=45MM OF HG

7.GOOD LV SYSTOLIC FUNCTION 

8.DIASTOLIC DYSFUNCTION PRESENT ;NO PE

9.IVC SIZE ( 0.75 CMS ) COLLAPSING

MRI 

BRAIN PLAIN

SMALL VESSEL ISCHEMIC CHANGES

DIFFUSE CEREBRAL ATROPHY- AGE RELATED

B/L FRONTOPARIETAL ; CORONA RADIATA ; DEGENERATIVE  CHANGES ; SMALL VESSEL ISCHEMIC CHANGES 

LACUNAR INFARCT NOTED IN THE RIGHT FRONTAL REGION BRIGHT ON T2 /FLAIR ; DWI

SUBACUTE LACUNAR INFARCT

HEMOGRAM

HB- 10.9 GM /DL

TLC - 14;100 CELLS /CUMM

RBC - 4.61 MILLION /CUMM

PLC - 2.77 LAKHS /CUMM

RFT-

BLOOD UREA- 33 MG /DL

SERUM CREATININE- 1.2 MG /DL

SERUM SODIUM- 134mEQ/L

SERUM POTASSIUM-3.6mEQ/L

SERUM CHLORIDE- 101 mEQ/L

LFT

TB-0.98 MG/DL

DB- 0.20 MG/DL

SGPT- 15 IU/L

SGOT- 26IU/L

ALP- 155IU/L

TP-6.8 GM/DL

ALBUMIN-4 GM/DL

A/G- 1.46


PROVISIONAL DIAGNOSIS-

PYREXIA UNDER EVALUATION WITH CVA 

ACUTE ISCHEMIC STROKE - R LACUNAR INFARCT IN FRONTAL LOBE WITH HYPERTENSION URGENCY (RESOLVED ) WITH K/C/O HTN SINCE 10 YEARS


TREATMENT


INJ . NEOMOL 1GM /IV/SOS

INJ.PAN 40 MG /IV/ OD

TAB ECOSPRIN AV 75/10 PI/HS

TAB.TELMISARTAN + METOPROLOL (40+12.5)





OSCE QUESTIONS

1. List all the complaints of the patient with respect to the history

 FEVER A/W COLD REFUSAL TO EAT FOOD ; UNABLE TO SPEAK PROPERLT ) WITH URINARY INCONTINANCE 

2. What is the personal history of the patient 

PERSONAL H/0:

APPETITE- DECREASED SINCE 5/10/2023 EVENING 

MIXED DIET

BOWEL- REGULAR

BLADDER - INCONTINENCE SINCE 5/10/2023 EVENING

NO ADDICTIONS  

3. Give a brief note on systemic examination. 

CNS - 

LEVEL OF CONSCIOUSNESS - DROWSY AROUSABLE

SPEECH - SLURRED

NO NECK STIFFNESS 

KERNIGS SIGN- ABSENT

CRANIAL NERVES- COULDNOT BE ELICITED

MOTOR SYSTEM- 

                RT LT

TONE UL N N

           LL N N

SENSORY SYTEM - COULNOT BE ELICITED

GLASGOW SCALE- E3V5M5 12/15

POWER RT LT

               UL 3/5 3/5

               LL 3/5 3/5 

REFLEXES BICEPS ; TRICEPS ; KNEE REFLEX OF RL - PRESENT

CEREBELLAR SIGNS- COULNOT BE ELEICITED

GAIT - NORMAL

CNS EXAMINATION 

1. HIGHER MENTAL FUNCTIONS:

a. Conscious-drowsy but arousable

Speech - slurred

d. Memory – immediate-retention and recall, recent and remote are present

e. No delusions, hallucinations

f. No Emotional lability


2.CRANIAL NERVE - Right left

                                Normal Normal

3.MOTOR SYSTEM-    Bulk

                     RIGHT    LEFT

Inspection  Normal Normal

Palpation    Normal Normal 

Measurement

Upper limb – 10cm below acromion ( same on both)Lower limb 18 cm below tibial tubercle (same on both)

Tone         RIGHT   LEFT

Upperlimb Normal Normal

Lowerlimb Normal Normal

Power

a. Neck muscles Good 

b. Upper limbs    Good       

i) Shoulder 

Flexion-Extension                          5/5  5/5                        

Lateral Rotation-Medial Rotation 5/5 5/5

Abduction -Adduction                    5/5 5/5

ii) Elbow

Flexion-Extensi                                5/5 5/5

iii) Wrist

Dorsi flexion-Palmar flexion          5/5 5/5

Abduction-Adduction                         5/5 5/5

Pronation-Supination 5/5 5/5

iv) small muscles of hand Good Good 

v) Hand grip Good Good

c. Lower limbs

i) Hip                        

Flexion-Extension  5/5 5/5

Abduction-Adduction 5/5 5/5

Lateral Rotation-Medial Rotation 5/5 5/5

ii) Knee

Flexion-Extension 5/5 5/5

iii) Ankle

Dorsi flexion-Plantar flexion 5/5 5/5

Inversion-Eversion 5/5 5/5

iv) Small muscles of foot Good Good

REFLEXES 

SUPERFICIAL REFLEXES 

                             RIGHT  LEFT

A.Corneal reflex Present Present

B.Conjunctival reflex Present Present   

C.Abdominal reflex Present Presen

D.Plantar reflex Present Present   

DEEP REFLEXES 

A.Biceps +2 +2

B.Triceps +2 +2

C.Supinator +2 +2

D.Knee jerk +2 +2

E.Ankle jerk +2 +2

SENSORY SYSTEM Normal Normal

CEREBELLAR SIGNS Absent Absent

SIGNS OF MENINGEAL IRRITATION Absent 

4. What are all Investigations that are done to the patient ? 

HEMOGRAM

HB- 10.9 GM /DL

TLC - 14;100 CELLS /CUMM

RBC - 4.61 MILLION /CUMM

PLC - 2.77 LAKHS /CUMM

RFT-

BLOOD UREA- 33 MG /DL

SERUM CREATININE- 1.2 MG /DL

SERUM SODIUM- 134mEQ/L

SERUM POTASSIUM-3.6mEQ/L

SERUM CHLORIDE- 101 mEQ/L

LFT

TB-0.98 MG/DL

DB- 0.20 MG/DL

SGPT- 15 IU/L

SGOT- 26IU/L

ALP- 155IU/L

TP-6.8 GM/DL

ALBUMIN-4 GM/DL

A/G- 1.46

MRI 

BRAIN PLAIN

SMALL VESSEL ISCHEMIC CHANGES

DIFFUSE CEREBRAL ATROPHY- AGE RELATED

B/L FRONTOPARIETAL ; CORONA RADIATA ; DEGENERATIVE CHANGES ; SMALL VESSEL ISCHEMIC CHANGES 

LACUNAR INFARCT NOTED IN THE RIGHT FRONTAL REGION BRIGHT ON T2 /FLAIR ; DWI

SUBACUTE LACUNAR INFARCT 

5. Plan of action ? 

TREATMENT

INJ . NEOMOL 1GM /IV/SOS

INJ.PAN 40 MG /IV/ OD

TAB ECOSPRIN AV 75/10 PI/HS

TAB.TELMISARTAN + METOPROLOL (40+12.5)


























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