A 85 yr old female with weakness of right upper limb and lower limb

 

This is an 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 patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome


Name :- P. Sai Krupa Sri 

Roll no :- 175 

A 85 yr old female with weakness of right upper limb and lower limb

Chief complaints : 

•Right sided weakness of hand and leg since 1 day

History of present illness : 

•Patient was apparently asymptomatic 1 day back 

•later she developed weakness of right sided upper and lower limb which is sudden in onset associated with deviation of mouth to the left , head fixed to left side.

•No History of seizures and no History of loss of consciousness and no history of headache and vomiting.

Past history : 

• no similar complaints in the past 

•Patient is Known case of hypertension since 10 yrs she was on medication tab telma 40mg 

•The patient went to near by hospital with complaint of burning sensation 4yrs back  she was on sedative  

•No History of diabetes , tuberculosis , asthma ,  epilepsy , thyroidal illness and HIV 


Personal history :-

Diet - mixed 

Appetite - normal 

Sleep - adequate 

Bowel and bladder movement - regular 

No addictions 


Family history :- 

Not significant


General examination:-

Patient was conscious , not cooperative ,not oriented to time, place ,person.

Moderately built and moderately nourished 

No pallor 

No icterus 

No cyanosis 

No clubbing 

No pedal edema 

No lymphadenopathy 


VITALS: 

Temperature : Afebrile 

pulse rate : 89 bpm

Respiratory rate : 22cycles / min 

BP: 150/90mmHg 

SpO2 - 98% at room air 


Systemic examination :- 

CNS :- 

Higher mental functions: 

• Consciousness is present

• Speech - global aphasia

Motor system : 

Tone                       Right                   Left 

Upper limb           increase              normal 

Lower limb           normal                  normal

Power : 

Upper limb -               0/5                   5/5    

Lower limb                 1/5                   5/5


Reflexes                     Right               Left       


Biceps.                            3+                 2+

Triceps.                           3+                2+

Supinator.                       3+                2+

Knee                                3+                2+

Ankle                               1+                1+

Plantar.                     Extension       Flexion.

Abdominal reflex - absent 

CVS - S1, S2 heard , No murmurs

RS - BAE +, NVBS +

P/A - Soft, Non tender

Investigation:- 


Hemogram :-

•Hemoglobin: 13.1 

•TLC: 13,200 

•neutrophils : 85 

•lymphocytes: 9 

•eosinophils: 2 

•monocytes : 4 

•PCV : 39.6 

•MCV: 75.9 

•MCH: 25.2

•RBC  : 5.35 million cells/ micro liter

•Platelets : 3.35 lakhs  


LFT: 

•total bilirubin : 1.21  

•DB: 0.31 

•AST: 16 

•ALT: 16 

•AKP: 222 

•total proteins : 7.4 

•Albumin : 4.23 

•A/G: 1.33 

RFT 

•Blood urea : 34 

•creatinine : 0.7 

•sodium: 144 

•Potassium : 3.6  

•chlorine: 97

Ultra sound :- 


Colour Doppler 2D ECHO :-

Diastolic dysfunction is present

ECG :- 
 


Clinical images:- 













Provisional diagnosis:- 

• Cerebrovascular accident with right sided hemiplegia with acute infarct in left capsuloganglionic region( Involving MCA Territory) with Upper motor neuron facial palsy 
•A known case of hypertension 

Treatment 
      
1. RT FGEDS
a)200ml milk- every 2nd hourly 
b)100ml water - every hourly             
2.Tablet ecospirin 150 MG /RT/OD               
3. Tab clopidogrel 75mg/RT/OD.                   
4. Tab Atorvas 40mg/RT/OD/ H/S.                 
5. Inj Pan 40mg/IV/OD.                                    
6. Physiotherapy of right upper limb and right lower limb
7. BP monitoring 2nd hrly .
8. GRBS monitoring at 8am __ 2pm __ 8pm
9. Inform SOS













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