Self reflective writing on their medical student care
1) Self reflective writing on their medical student career
This is an online e log book to discuss our patient identified health data shared after taking his/her guardian signed informed consent. Here we discuss our individual patient problems through a series of inputs from available global online community of experts with a aim to solve those patients clinical problem with collective current best evidence based inputs.This blog also reflects my patient centered online learning portfolio and valuable inputs on the comments box is welcome.I have been given this case to solve in an attempts to understand the topic of patient clinical data analysis, to develop my competency in reading and comprehending clinical data including history, clinical finding, investigation.
I AM SOWMIKA MARRU OF 2017 BATCH DOING INTERNSHIP …….36 yr old male patient presented to opd with
c/o Fever since 4 days
C/o of 7 episodes of loose stools
https://sowmikamarru5.blogspot.com/2023/09/38-year-old-male-with-fever-since-4-days.html
Next week -
A 78 year old male came to casualty with
c/o weakness of right upper limb and lower limb since 4 days.
C/o inability to talk since 4 days
[11/09/23, 7:08:39 PM] 78M WEAKNESS RIGHT UL AND LL 4 days Left UĹ LĹ 2 mths Telangana PaJR: Messages and calls are end-to-end encrypted. No one outside of this chat, not even WhatsApp, can read or listen to them.
[11/09/23, 7:08:39 PM] 78M WEAKNESS RIGHT UL AND LL 4 days Left UĹ LĹ 2 mths Telangana PaJR: You created group “A 78/M CAME WITH C/O WEAKNESS IN RIGHT UL AND LL SINCE 4 days”
[11/09/23, 7:10:51 PM] 78M WEAKNESS RIGHT UL AND LL 4 days Left UĹ LĹ 2 mths Telangana PaJR: You changed the group description
[11/09/23, 7:18:51 PM] Harika Pg Maam: Make me admin
[11/09/23, 7:22:06 PM] 78M WEAKNESS RIGHT UL AND LL 4 days Left UĹ LĹ 2 mths Telangana PaJR: You changed the group description
[11/09/23, 7:24:23 PM] 78M WEAKNESS RIGHT UL AND LL 4 days Left UĹ LĹ 2 mths Telangana PaJR: You changed the group name to “A 78/M CAME WITH C/O WEAKNESS IN RIGHT UL AND LL SINCE 4 days PaJR Telangana”
[11/09/23, 9:42:32 PM] 78M WEAKNESS RIGHT UL AND LL 4 days Left UĹ LĹ 2 mths Telangana PaJR: Harika Pg Maam added Dr. Ajay Kumar Reddy Pg, Govardini Ma’am Pg, and 11 others. Tap to see all.
[11/09/23, 9:43:06 PM] Rakesh Biswas Sir GM HOD: Harika Pg Maam added Rakesh Biswas Sir GM HOD
[11/09/23, 10:05:47 PM] Rakesh Biswas Sir GM HOD: Make me admin
[11/09/23, 10:16:10 PM] Rakesh Biswas Sir GM HOD: Rakesh Biswas Sir GM HOD changed the group name to “78M WEAKNESS RIGHT UL AND LL 4 days Left UĹ LĹ 2 mths Telangana PaJR”
[11/09/23, 10:17:14 PM] Rakesh Biswas Sir GM HOD: @919100206300 Remove the eye images
[11/09/23, 10:17:41 PM] sowmika marru: Ok sir
[11/09/23, 10:18:21 PM] Rakesh Biswas Sir GM HOD: https://asjad24.blogspot.com/2023/09/was-apparently-asymptomatic-till-last.html
[11/09/23, 10:18:34 PM] Rakesh Biswas Sir GM HOD: Rakesh Biswas Sir GM HOD changed the group description
[11/09/23, 10:19:05 PM] ~ Dr.Dinesh Datta: ~ Dr.Dinesh Datta joined using this group's invite link
[11/09/23, 10:20:11 PM] +91 96188 60147: +91 96188 60147 joined using this group's invite link
[11/09/23, 10:20:39 PM] ~ Asjad: ~ Asjad joined using this group's invite link
[11/09/23, 10:28:04 PM] +91 83414 36269: +91 83414 36269 joined using this group's invite link
[11/09/23, 10:28:13 PM] ~ Sneha: ~ Sneha joined using this group's invite link
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[12/09/23, 4:59:01 AM] ~ Dr. Avinash Kumar Gupta: ~ Dr. Avinash Kumar Gupta joined using this group's invite link
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[12/09/23, 10:06:54 AM] sowmika marru: Date- 12/9/23
AMC
Unit-6
Date of admission 9/9/23
S- c/o weakness of right UL and LL since 5 days
C/o inability to talk since 5 days
C/o hiccups since 2 days
O- on examination, patient is conscious, coherent, cooperative.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, oedema.
Vitals-
Bp- 130/90mmhg
Temp- 98.2 F
PR- 77 bpm
RR- 17cpm
CVS - s1, s2 heard
RS - BAE present, NVBS
P/A- soft , non tender, no organomegaly
CNS - Higher mental functions - intact
Cranial nerves - intact
Motor examination: R L
Bulk. N N
Tone. UL Hypo Hypo
LL Hyper Hyper
Power. UL 0/5 3/5
LL. 0/5 2/5
Reflexes:
Biceps. 3+ 3+
Triceps. 1+ 1+
Supinator 1+ 1+
Knee 2+ 2+
Ankle. 1+ 1+
Plantar. Extensor. Flexor
Sensory examination:Normal
No meningeal signs
A-
Right hemiplegia with acute infarct in left superior frontal lobe ( left ACA territory)With K/C/O left hemiparesis since 2 years.
K/C/O HTN since 2 years.
P -
1) ryles tube feeds
2nd hourly water 100ml
4th hourly milk 100ml
2) TAB. ECOSPRIN- AV 10mg PO/OD
3) TAB. AMLONG 10mg PO/OD
4) INJ. CEFTRIAXONE 1gm IV / BD
5) physiotherapy of B/L UL and LL
[12/09/23, 10:26:56 AM] Rakesh Biswas Sir GM HOD: Can you answer the questions posed about this patient in the 2018 ward group?
[12/09/23, 11:12:27 AM] sowmika marru: [9/11, 9:26 PM] +91 76073 78390: https://asjad24.blogspot.com/2023/09/was-apparently-asymptomatic-till-last.html
[9/11, 9:26 PM] +91 76073 78390: Problem list:
1) Uncontrolled hypertension
2) Uncontrolled Blood sugar
3)In ability to speak
4)Inability to move right upper and lower limb
[9/11, 9:26 PM] +91 76073 78390: List of questions raised around this patient.
1) Cause of his sudden Slurring of speech.
2) Clinical localisation of stroke(cortical or subcortical)
3)Clinically interpreting the vessel involved (aca/mca/pca)
4) Does his uncontrolled hypertension lead to stroke?
[9/11, 9:30 PM] Rakesh Biswas: 1) Share the BP charts since admission
2) Share the blood sugar charts since admission
3) What kind of speech therapy will help him? Have you tested the power of his muscles of speech?
Share the details of your muscle testing of his limbs as well as reflexes and tone
[9/11, 10:08 PM] +91 76073 78390: Tone:-
Rt UL - Hyper
Rt LL-Hyper
Lt LL-Hypo
Lt LL- Hyper
Power:-
Rt UL - 0/5
Lt UL-2/5
Rt LL - 0/5
Lt LL-2/5
Reflexes:
RIGHT
Biceps: +++
Triceps: +++
Supinator: ++
Knee: +++
Ankle: +++
Plantar: Extensor
LEFT
Biceps: +++
Triceps: ++
Supinator: ++
Knee: ++
Ankle: ++
Plantar: Extensor
[9/11, 10:08 PM] +91 76073 78390: It can be due to subcortical involvement as there is no history of loss of consciousness which is suggestive of cortical involvement.
[9/11, 10:08 PM] +91 76073 78390: BP:
9/9 : 160/100 mm Hg
10/9 : 170/100 mm Hg
11/9 : 150/90 mm Hg
[9/11, 10:08 PM] +91 76073 78390: There is no cranial nerve involvement as spontaneous reaction to light was present so PCA involvement can be ruled out.
Dense weakness is seen so may be lesion can be at the level of corona radiata or internal capsule with the involvement of ACA.
[9/11, 10:14 PM] Rakesh Biswas: The patient's tone doesn't match with power?
[9/11, 10:18 PM] Rakesh Biswas: https://chat.whatsapp.com/HlcV38zg0Zn4INKQIPrn3i
[12/09/23, 11:12:27 AM] sowmika marru: 1) CVA 2 years back
2) https://ne.neurology.org/content/1/1/e200012
3) https://pubmed.ncbi.nlm.nih.gov/30726018/
4) A stroke occurs when a blood vessel to the brain is narrowed or blocked by a clot (ischemic stroke) or bursts (hemorrhagic stroke). When that happens, part of the brain is no longer getting the blood and oxygen it needs; so it starts to die. Your brain controls your movement and thoughts, so a stroke threatens your ability to think, move and function. Strokes also can affect language, memory and vision. Severe strokes may even cause paralysis or death.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409792/
[12/09/23, 11:12:27 AM] sowmika marru: <attached: 00000031-PHOTO-2023-09-12-11-12-27.jpg>
[12/09/23, 11:12:27 AM] sowmika marru: <attached: 00000032-PHOTO-2023-09-12-11-12-27.jpg>
[12/09/23, 11:28:08 AM] ~ .: ~ . left
[12/09/23, 1:40:23 PM] +91 90592 28535: +91 90592 28535 joined using this group's invite link
[12/09/23, 4:56:29 PM] Rakesh Biswas Sir GM HOD: Not sure what 2 and 3 is but 4 doesn't appear to have any context as to why it was shared!!
[12/09/23, 5:16:35 PM] ~ Asjad: Right upper limb
Flexion of elbow - hypotonia
Flexion of wrist - hypotonia
Flexion of fingers - hypertonia
Right Lower limb - hypertonia
Left upper and lower limb - hypertonia
Power
Right ul - 0/5
right ll - 0/5
Left upper limb - 3/5
Left lower limb - 2/5
[12/09/23, 5:16:47 PM] ~ Asjad: Sir as of today evening
[12/09/23, 5:23:45 PM] Rakesh Biswas Sir GM HOD: Also share the new patient that you saw today
[12/09/23, 5:24:35 PM] ~ Asjad: Okay sir
[13/09/23, 5:36:10 AM] ~ Madeeha Abrar: ~ Madeeha Abrar joined using this group's invite link
[14/09/23, 4:35:53 PM] Rakesh Biswas Sir GM HOD: Update?
[14/09/23, 5:02:11 PM] Harika Pg Maam: Patient went on LAMA
Today sir
1. Cortical Stroke:
A cortical stroke occurs in the outer layer of the brain [cerebral cortex] which is responsible for higher order brain functions, like thinking, perception, and voluntary movements
Symptoms - often involve changes in sensory perception, motor control, and cognition.
Depending on the specific area of the cortex affected, patients may experience symptoms like :
aphasia (language problems)
apraxia (motor coordination difficulties)
agnosia (impaired recognition of objects or people).
2. Subcortical Stroke:
Subcortical strokes occur in the deeper regions of the brain [ beneath the cerebral cortex] . These areas are responsible for regulating and coordinating basic functions such as movement, sensation, and some aspects of consciousness.
Symptoms - can be more related to motor control and may include muscle weakness
Memory impairment
Apathy
INVOLVEMENT OF ACA [VS] MCA [VS ] PCA-
1. Middle Cerebral Artery (MCA)-
symptoms may often affect the opposite side causing weakness or paralysis of the face and arm.
sensory changes in the opposite side
speech and language problems, like aphasia.
Cognitive and emotional changes.
Visual disturbances.
2. Anterior Cerebral Artery (ACA)-
This can lead to contralateral leg weakness and sensory loss.
changes in motor function, especially in the lower extremities.
3. Posterior Cerebral Artery (PCA) -
Results in visual disturbances, such as homonymous hemianopia (loss of vision on the same side in both eyes).
memory problems .
altered consciousness.
1. Increased Stress on Blood Vessels- High blood pressure puts excessive force on the walls of blood vessels, especially the small arteries in the brain. Over time, this can damage and weaken the blood vessel walls.
2. Atherosclerosis- Hypertension can lead to the development of atherosclerosis, a condition where fatty deposits build up inside arteries. This can narrow the blood vessels, reducing blood flow to the brain.
3. Formation of Blood Clots- The turbulent blood flow caused by high blood pressure can result in the formation of blood clots in the narrowed or damaged blood vessels. These clots can block blood flow to parts of the brain.
4. Hemorrhagic Strokes- Uncontrolled hypertension can weaken blood vessel walls to the point of rupture, causing a hemorrhagic stroke. This type of stroke occurs when a blood vessel in the brain bursts, leading to bleeding in the brain tissue.
5. Reduced Oxygen Supply- High blood pressure can decrease the supply of oxygen and nutrients to brain cells, increasing the risk of damage to the brain.
6. Damage to Small Blood Vessels- Chronic hypertension can lead to the gradual damage of small blood vessels throughout the brain, which can result in cerebral small vessel disease (CSVD).
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