65 year old female with hemiparesis

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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 diagnosis and treatment plan.

Case; 

A 65 year old female complaints of 

deviation of mouth to left side 

weakness in his right upper and lower limbs  

Chief complaints 

Patient complaints of ; 

Weakness of right upper and lower limbs 

Slurring of speech since 3 pm on yesterday

History of presenting illness:

Patient was apparently asymptomatic yesterday afternoon 

Then she suddenly developed weakness in her right upper and lower limbs 

Associated with deviation of mouth to left side and slurring of speech since 3pm yesterday 

She has no complaints of fever , vomitings, loose stools 

No h/o giddiness or loss of consciousness 

No c/o involuntary movements, tingling sensation /paresthesis 

No c/o decreased urine output, pedal edema, burning micturition 

No c/o chest pain , palpitations, syncopal attacks

Past history: 

H/o cva rt sided (rt upper and lower limbs) 4 years back used medication for 1 and half year and then stopped 

K/c/o DM 5 years back on tab metformin 500mg + tab glimeperide 1 mg 

Not a k/c/o HTN, Asthma, epilepsy, CAD 

Personal history: 

Diet : mixed 

Appetite: normal 

Sleep: adequate 

Addictions: none 

Allergies: none 

General examination; 

Pt is conscious coherent and cooperative 

Oriented to time place and person 

Moderately built and nourished 

Vitals: 

BP: 130/80 mm Hg 

PR: 86bpm

Spo2: 99% 

Temp: afebrile 

      

Systemic examination: 

CVS: s1 s2 heard 

        No murmurs 

Respiratory system; normal vesicular breath sounds are heard 

Abdomen: soft non tender no organomegly

CNS;

Higher functions:

Right handed 

Conscious 

Oriented to time  place and person 

Memory: recent- present 

              Immediate: present 

              Remote: present 

Speech:

           Slurred 

            comprehension- present 

            Naming- present 

            Repitition- absent 

           

No delusions or hallucinations 

Cranial nerve examination:

I- Olfactory nerve-  sense of smell present 

II- Optic nerve- direct and indirect light reflex present

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis

V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.

VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.

VIII- Vestibulocochlear nerve- no hearing loss

IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised

XI- Accessory nerve- sternocleidomastoid contraction present

XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue

Spinomotor system:

                                            Right                         Left  

BULK:              U/L-           Normal                       Normal 

                            

                                      

                         L/L-          Normal                      Normal 

                                

                  

TONE:            U/L       decreased                       normal

                        L/L        decreased                       normal

                          

                                           Right                                  Left 

POWER:       U/L- hand           0/5                                   4/5

                            - elbow         0/5                                   4/5

                            - shoulder     0/5                                     4/5

                    L/L- hip              3/5                                   4/5

                           - knee           3/5                                   4/5   

                            - ankle          3/5                                   4/5

                                       Right                                        Left        

REFLEXES:    Biceps                ++                                   -

                        Triceps                -                                      - 

                    Supinator                -                                       - 

                          Knee                   -                                      -

                        Ankle                 -                                        -

                          Plantar          extension                          Flexion 

4c) Sensory system examination:

                                          Right                                  Left  

• crude touch                  present                             present
• fine touch                      absent                             present              
• pain                               absent                             present
• vibration                      absent                              present
• temperature                     absent                            present
• stereognosis-                  absent                              present 
• 2 pt discrimination-           absent                        present

Investigations: 

Hemogram : 

On 21-10-22

      

 On 22-10-22: 

      

RBS: 

LFT : 

RFT: 

Serum electrolytes: 

Serum creatinine: 

X rays: 

CT brain:  

CT brain report: 

MRI brain : 

2D ECHO: 

PROVISIONAL DIAGNOSIS:

Acute ischemic stroke causing right sided hemiplegia ( left MCA territory) 

TREATMENT:

Tab. Ecosporin 150mg

Tab. Clopidogrel 75 mg

Tab. Atorvas 40mg

Tab. Atenolol 25mg

Physiotherapy