53/M with altered sensorium secondary to? RECURRENT CVA WITH HTN AND TYPE 2 DM

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I've 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.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

Cheif complaints:

Patient was brought to the casuality with complaints of slurry of speech  since afternoon. 

HOPI:

Patient was apparently normal 12 years back then had trauma(fall in to well) 

And had head injury 

He developed weakness of left upper and lower limbs, which was insidious in onset and gradually progressive,  Weakness associated with slurry speech 

No c/o drooling of saliva, deviation of mouth

Patient took treatment and there was improvement in symptoms since. 

Then on 04/05/2023 afternoon patient developed difficulty in speech and was unable to get up from bed

Patient had history of trauma 7 days back and injury to left ankle (?fracture of calceneum) 

No involuntary micturation and defecation

No h/o fever, vomiting,pain abdomen,loose stools,giddiness

H/o CVA 12 years back and on medication for the same

K/c/o htn since 14 years and on medication

K/c/o type 2 DM since 10 years and on medication (Glimeperide 1mg) 

Not a k/c/o CAD  BA EPILEPSY

H/o smoking for 40 years

Personal history:

Diet: mixed 

Appetite: normal

Sleep: Adequate 

Bowel and bladder:decreased micturition for 1 day , normal bowel movements 

H/o smoking for 40 years

GENERAL EXAMINATION:

Vitals:

BP 180/100 MMHG

PR 62 BPM

RR 18/MIN

SpO2 99% At RA

 No pallor,No icterus, cyanosis, clubbing, lymphadenopathy. 

SYSTEMIC EXAMINATION ::

GIT

INSPECTION :

Abdomen - scaphoid 

Umbilicus - inverted 

Movements - all quadrants are equally moving with respiration

No scars and sinuses 

No visible peristalsis

No engorged veins.

PALPATION:

No local rise in temperature and no tenderness in all quadrants 

LIVER: no hepatomegly

SPLEEN- not enlarged 

KIDNEYS - bimanual palpable kidneys 

PERCUSSION :

no shifting dullness

AUSCULTATION :

Bowel sounds are heard and are normal

No bruit

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical

Type of respiration: thoraco abdominal.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- absent.

Vocal fremitus- normal on both sides.

Percussion:                   

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

Bilateral Airway entry - present. 

Decreased BS on the left side.

B/L crepts present in basal areas,wheeze present.

Cardiovascular system:

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

Central Nervous system:

Higher motor functions- patient is drowsy but arousable

Speech: Slurry

PUPILS:B/L NORMAL SIZE REACTING TO LIGHT.

Cranial nerve functions - cannot be elicited 

Sensory system- cannot be elicited

TONE:   RT.                     LT

   UL:   INCREASED NORMAL

  

  LL:.    NORMAL      NORMAL

POWER:

   UL.          4               4

    LL.          4               4

REFLEXES:

        B:   3+         2+

        T:   2+         2+

        S:   2+         2+

        K:   3+        2+

        A:   -        -

        P:   EXT.     NOT ELICITED

On 05/05/2023

S:

NO FEVER SPIKES

STOOLS NOT PASSED 

O:

ON EXAMINATION:

Patient is drowsy but arousable

Gcs:E4V5M6

BP:180/100mmhg.

PR:62BPM

RR:17CPM

TEMP:97.9F

CVS:S1,S2 HEARD ,NO MURMURS. 

RS:BAE+,NVBS.

CNS:PUPILS:B/L NORMAL SIZE REACTING TO LIGHT.

TONE:   RT.                     LT

   UL:   INCREASED NORMAL

    

  LL:.    NORMAL      NORMAL

POWER:

   UL.          4               4

    LL.          4               4

REFLEXES:

        B:   3+         2+

        T:   2+         2+

        S:   2+         2+

        K:   3+        2+

        A:   -        -

        P:   EXT.     NOT ELICITED

A:

ALTERED SENSORIUM UNDER EVALUATION  2°TO RECURRENT CVA (OLD CVA LT. HEMIPARESIS 12 YEARS BACK)  WITH HYPERTENSION WITH DM 2 WITH AKI ON? CKD

P:

INJ. HAI S/C TID ACC TO GRBS

TAB ECOSPIRIN 75/20MG PO/ HS

GRBS 7 PROFILE MONITORING

HOURLY BP MONITORING