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Case Discussion: Right Hemiparesis

1/11/2021
Samhita Ghanathay
  • This is an online E log book to discuss our patient's de-identified health data shared after taking her/his 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 patient's 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 the comment box is welcome.

62 year old Female with sudden onset weakness of right limbs.

I've been given this case to solve, in an attempt to understand the topic of "patient clinical data analysis" to develope my competency  in reading and comprehending clinical data - including history, clinical findings, investigations - and come up with diagnosis and treatment plan.

Following is a brief about the case,
(History as per date of admission).

CHIEF COMPLAINTS: 

A 62 year old lady, who used to work as a laborer, now a homemaker, resident of Bhuvanagiri was brought to the Medicine OPD with complaints of: 

• Sudden onset weakness in right upper and lower limbs.
• Deviation of angle of mouth to the right.

HISTORY OF PRESENT ILLNESS: 

The patient is apparently asymptomatic 1 day. 

6 months ago, she developed diminission of vision in the left eye ,which was insidious in onset and gradually progressive.

She came to the ophthalmology OPD on 27/10/21 and was diagnosed with immature senile cataract in the left eye - for which she  underwent cataract surgery to the left eye on 30/10/21.

She was asked to stay at the hospital for a day, for a regular supervision post surgery.

On the morning of 31/10/2021, at around 4 am she fell from bed onto the ground. The attended put her back to sleep on the bed. 

When she came back at around 6am to wake her up, the attender noticed the patient had a deviation of mouth to left and unable to lift her right upper and lower limbs, unable to speak and was referred to general medicine department. 

PAST HISTORY:

•Under went cataract surgery in the right eye 3 years ago.

•K/c/o HTN - since 10 years- on tab.telma h ( 40/12.5) mg PO OD.

•K/c/o Type 2 DM- since 5 years- On tab.glyciphage sr 500 mg PO OD.

•Not a k/c/o TB ,asthma ,epilepsy.


PERSONAL HISTORY: 

•Married

•Takes mixed diet

•Appetite - normal

•Sleep - adequate

•Bowel and bladder movements - regular

•No known addictions and allergies


GENERAL PHYSICAL EXAMINATION: 

Patient is conscious, coherent, cooperative

Moderately built and nourished

No pallor ,icterus, clubbing ,cyanosis  lymphadenopathy, odema of feet.

Vitals

Temperature- Afebrile.

Pulse rate - 94 bpm

BP- 120/70 mm Hg

Respiratory rate - 18 cpm


SYSTEMIC EXAMINATION: 

CVS - S1,S2 heard.

Resp. System - normal breath sounds heard (BAE positive).

P/A- soft , nontender.

CNS - higher mental functions intact.

-PUPILS -

       Rt - pinpoint pupil

       Lt - reacting to light      

-Speech - aphasia


-Power                 UL                       LL

                 Rt.      0/5.                   5/5

                 Lt.      4/5.                   5/5

 

-Tone         Rt    Decreased.         Normal 

                  Lt    decreased           Normal

-Reflexes 

             B     T      S     K      A     P

Rt.       1+    1+    -      2+    -      flexor

Lt         2+   1+    1+   2+    2+   Flexor 


INVESTIGATIONS: 

Investigations ordered: CBP, LFT  2D Echo, and ECG.

Serology : Negative.

CBP : Normal - with high FBG.


LFT : Normal.


ECG: 
31/10/2021


01/11/2021




ECHO: 


CT Brain : Impression:-

•Chronic lacunar infarcts noted in bilateral lentiform nucleus.

•Diffuse cerebral atrophy

•Left occipital bone fracture?


PROVISIONAL DIAGNOSIS:

• Right hemiparesis.

• Acute CVA.


TREATMENT: 

•TAB. CIFRAN 500MG PO BD
•TAB. ECOSPRIN 75MG PO H/S
•TAB. CLOIDOGRIL 75 MG PO H/S
•TAB. ATROVAS 40 MG PO H/S
•TAB. METFORMIN SR 500MG PO OD
•TAB.TELMA 40 MG PO OD
•TAB. FLEXON PO BD
•INJ. MANNITOL 100ML IV BD

NOTE: 
FINAL DIAGNOSIS: 
RIGHT SIDED HEMIPARESIS (RESOLVED )
SECONDARY TO ACUTE ISCHEMIC STROKE 
SUBACUTE INFRACT IN THE L INTERNAL CAPSULE POSTERIOR LIMB.
K/C/O HTN
K/C/O TYPE 2 DM.

• She was discharged 3 days later, after complete recovery.














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