65 year old female with hemiparesis



 This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

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




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