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75 year old with right hemiparesis and slurring of speech

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.




This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


I have 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.


This is a case of a 75 year old lady who presented with weakness of right upper and lower limbs and slurring of speech since one day


HISTORY OF PRESENTING ILLNESS

The patient was apparently asymptomatic until 4 months ago and then she began experiencing bilateral knee pains right leg greater than the left leg. She went to the hospital and was given treatment

Events leading to the current presentation:

The patient woke up in the morning as usual and did her daily chores which comprise of sweeping the house and other activities and had lunch at 12 and then had an afternoon nap. When she woke up she was not able to get out of the bed and was not able to move her right upper and lower limb. She also experienced slurring of speech and there is also a change in voice.

Not associated with blurring/diminision of vision, dizziness, numbness of tongue

No c/o weakness of limbs,seizures,headache,sensory symptoms 

No c/o burning micturition,cough,SOB,vomiting,loose stools 

No H/o head trauma.


Daily Routine:

The patient’s attender remarked that the patient was a very active person and is an amicable person. She wakes up at 6 AM and sweeps the house after freshening up. She helps in minor chores around the house. She has lunch at 12 and sleeps for some time in the afternoon. After she wakes up she chats with the neighbours and has dinner at 7 and sleeps by 8 PM.


PAST HISTORY

The patient was diagnosed with hypertension 15 years back and is on medication since then

The patient also has frequent bloating and epigastric pain and uses medication

No history of diabetes, epilepsy, asthma, thyroid disorders


TREATMENT HISTORY


Etizolam
Rabeprazole sodium and levosulpride
Cinod-T

PERSONAL HISTORY 

Diet: mixed
Appetite: normal
Sleep: unable to sleep, experiences sleep disturbances. Uses etizolam


GENERAL EXAMINATION

Patient is conscious coherent and cooperative. Well oriented to time place and person

Pallor absent
Icterus absent
Clubbing absent
Cyanosis absent
Lymphadenopathy absent
Edema absent

Vitals
BP 141/90
PR 75 BPM
Temp afebrile
RR 16

















CNS EXAMINATION 


HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

speech : slurred, unable to pronounce cha, ja, va(12th cranial nerve?)

Behavior : normal 

Memory : Intact.

Intelligence : Normal

Lobar Functions : Normal.

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:

1st   : Normal

2nd  :  visual acuity is normal

           

3rd,4th,6th  :  pupillary reflexes present.

                      EOM full range of motion present

                      gaze evoked Nystagmus present.

5th             :  sensory intact

                      motor intact

7th             :  angle of mouth deviated to left side. loss of nasolabial fold on right side

8th             :  No abnormality noted.

9th,10th     : palatal movements present and equal.

11th,12th   : normal.

MOTOR EXAMINATION:                     Right                                           Left

                                           UL                            LL                      UL                    LL

   BULK                         Normal                    Normal                 Normal          Normal

   TONE                          hypotonia                hypotonia            normal         normal

   POWER                       0/5                          2/5                         5/5                 5/5


   SUPERFICIAL REFLEXES:
       
    CORNEAL                                     present                                           present

   CONJUNCTIVAL                          present                                           present

   PLANTAR                                     withdrawal                                      withdrawal

   DEEP TENDON REFLEXES:

   BICEPS                        3                               2                  

   TRICEPS                      3                              2                        

   SUPINATOR                1                                2                

   KNEE                            -                                 -                         

   ANKLE                         3                               1               

    

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch diminished on right upper limb

pain diminished on right upper limb


DORSAL COLUMN SENSATION:

Fine touch not able to perceive on right upper and lower limb

Proprioception normal

CORTICAL SENSATION:

Two point discrimination unable to discrimate on right upper and lower limb

Tactile localisation unable to do on right upper and lower limb






CEREBELLAR EXAMINATION:

  Finger nose test unable to preform with right hand

  Heel knee test unable to preform with right lower limv

  Dysdiadochokinesia not able to preform with right hand

  Nystagmus not seen

  Titubation not present

  

SIGNS OF MENINGEAL IRRITATION: absent

GAIT:

  unable to stand without support

 unsteady with a tendency to fall

unable to perform tandem walking.



CVS S1 S2 heard, no murmurs

RS BAE, no added breath sounds

ABDOMEN soft and non tender


INVESTIGATIONS 







PROVISIONAL DIAGNOSIS:


CVA with right hemiparesis secondary to acute infarct in left putamen








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