1601006198 LONG CASE

 

A 50 YEAR OLD FEMALE WITH LEFT SIDED HEMIPLEGIA AND DEVIATION OF MOUTH TOWARDS RIGHT.

LONG CASE:- 

Hall ticket no. 1601006198

This is an online e logbook to discuss our patient’s deidentified health data shared after taking guardian’s signed informed consent. 

Here we discuss our individual patient problems through series of inputs with an aim to solve those patient’s clinical problem with collective current best evidence based inputs. This slog also reflects my patient centered online learning portfolio .

A 50yr old lady,farmer by occupation, resident of suryapet presented to the hospital with chief complaints of 

•weakness of left upper and lower limb since 6 days

•Deviation of mouth towards right side since 6 days

History of presenting illness:-

The patient was apparently asymptomatic 6 days back when she  developed sudden onset of weakness in her left upper and lower limbs ,followed by fall with no history of trauma for which she got admitted in the hospital. There was slurring of speech and deviation of mouth to right side.

Not associated with altered sensorium or convulsions

No difficulty in closing her eyes or raising her eyebrows.

No history of headache or vomiting

No h/o bowel and bladder abnormalities,swallowing difficulty,blurring of vision

No h/o trauma,headache,nausea and vomiting

 Past history :-

-She is a known case of hypertension since 5yrs and diabetes since 3yrs

-No similar complaints in the past.

-No h/o epilepsy ,asthma, copd, coronary artery disease, blood transfusions,connective tissue disorders      

Family history:-             

No similar complaints in the family, 

And no family history of hypertension, diabetes, asthma , cardiac conditions.              

Menstrual history:- 

Age of menarche:- 15 years 

Last menstrual period on 11-4-2021 

patient underwent hysterectomy 4 years back for fibroid uterus.          

Personal history:- 

-She consumes mixed indian diet. 

-Normal appetite. 

-Sleep adequate. 

-Regular bowel and bladder movements. 

-History of alcohol consumption of 60 ml per day for 15 years now.

Allergic history:- 

No known allergies to any foods or drugs

Treatment history:- patient is on 

-Tab. Telmisartan 40mg OD 

-glimepiride 0.2mg, metformin 500 mg BD for 4 years now.

General examination:- 

•patient was conscious, coherent, cooperative.

•moderately built and nourished; central obesity present,oriented to time, place and person, comfortably lying on the bed.

•There's no pallor, icterus, cyanosis,clubbing, koilonychia, lymphadenopathy, edema

•Acanthosis nigricans seen on nape of the neck

•Vitals:-Temperature -afebrile

•Pulse rate-74bpm with regular rhythm ,character and volume,no radiofemoral delay 

•Blood pressure-110/85mmHg

•Respiratory rate-16cpm

Systemic examination

Central nervous system examination:-

1)Higher mental functions:- 

-patient is conscious,oriented to time ,place and person

-memory-immediate,recent and remote memory intact

-appearence-well kept

-speech- slurred

-right handedness

2) Cranial nerves:-

•Olfactory- can perceive the smell on both sides

•Optic- visual acuity -6/6,Visual field, colour vision, reflexes -normal 

•3,4,6 cranial nerves- ocular movements - normal

                                  -There's no ptosis or nystagmus.

                                  - Normal and reactive pupils

•Trigeminal -motor and sensory functions normal on both sides.

•Facial nerve:-  upper half of the face is spared

-Bilateral normal eyelid closure.

-frown lines on forehead present 

Lower face is affected:-

-deviation of angle of mouth towards right.

-absent nasolabial folds on left side

-blowing and whistling absent

-Sensory:- Taste sensation on anterior 2/3rd of tongue present

Corneal reflex:- present on both sides

•Vestibulocochlear nerve- Rinne's test - AC> BC; Weber's is centralised ,schwabach test normal on both sides

•Vagus and glossopharyngeal -gag reflex present ,uvula midline

•Spinal accessory- Trapezius and sternocleidomastoid are normal 

•Hypoglossal nerve -no deviation of tongue; normal movements

3. Motor system examination:-

a)Bulk:-               Rt.          Lt

                     Normal    normal

b)Muscle tone    Rt.          Lt

   Upperlimb.   Normal.   Hypotonia 

   Lowerlimb.   Normal    Hypotonia

c) Muscle power   Rt.       Lt

   Upper limb.       5/5.      0/5

   Lower limb.       5/5.      0/5 

d) Reflexes.         Rt.        Lt

    Superficial       

     Corneal.          +.         +

     Conjunctival.   +.         +

     Abdominal      +.          +

     plantar.        Flexor.     Extensor

 Deep tendon.     Rt            Lt

   Biceps.            2+            3+

   Triceps            2+            3+

   Supinator.       2+            2+

   Knee               2+            3+

   Ankle.             1+            2+

4) Sensory system examination:-

                            Rt.                Lt

•Pain.                  +.                   +

•Crude touch.      +.                   +

•Fine touch.         +.                   +

•Proprioception.   normal.        normal

•Stereognosis.     normal.        normal

•2 point discrimination normal.  Normal 

5) No signs of meningeal irritation.

Cardiovascular system:-

S1, S2 heard, no murmurs heard

Respiratory system :- 

Bilateral air entry present.

Normal vesicular breath sounds heard.

No adventitious sounds heard. 

Per abdomen:- soft, non tender

Provisional diagnosis:-

Left hemiplegia with left UMN facial palsy likely to be due to lesion in right internal capsule.

Deviation of mouth to right

          Video showing Extensor plantar reflex

Investigations:- CT brain showing hypodense infarcts, ECG. 

Treatment received:-

• 20 % MANNITOL I.V. - 20 gm
• TAB. ECOSPIRIN 150 mg OD
• TAB. ATORVASTATIN 40 mg OD
• TAB. CLOPIDOGREL 75 mg OD
• TAB. TRAMADOL BD
• Physiotherapy of left upper limb and lower limb