A 65 yrs old female with difficulty in moving left upper and lower limbs.

This is an online elog documenting de-identified patient health data after taking his signed consent to enforce a greater patient centered learning. 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CASE DISCUSSION :

A 65 yr old female coming from Rajavaram  was brought to the casualty with
 
CHIEF COMPLAINTS of:

Weakness in right and left upper limbs and lower limbs since 5 days

Difficulty in moving left upper limbs and lower limbs since 4days.

Inability to speak since 4 days.
 
Fever since 4 days.

HOPI

Patient was apparently asymptomatic 5 days back she developed weakness on Saturday in left upper and lower limbs which was sudden in onset , gradually progressed and is completely unable to move since 4 days.

She is also unable to speak due to deviation of mouth later that day

Next day ,the weakness of both limbs of left side became severe and completely lost her speech and not responding to commands.

She lost her consciousness and urinated involuntary and left sided hemiplagia occured and lost her speech and was bed ridden for 3 days.

 No H/O Head Trauma (for haemorrhagic stroke) 

No H/O Epilepsy

No H/O projectile vomiting, headache or blurring of vision

No H/O recent surgeries (for embolic stroke)

 PAST HISTORY:

No H/O similar complaints in the past

She is a known case of  hypertension and is on medication since 2 years.

 -No H/O DM, TB, Hypo/Hyperthyroidism/ Epilepsy/ Asthma/COPD/ CAD/ Blood transfusions/ Connective tissue disorders (stroke in young)

 -No H/O Major hospitalizations

 -No H/O major surgeries.

PAST HISTORY:

No H/O similar complaints in the past

She is a known case of hypertension and is on medication since 2 years.

 -No H/O DM, TB, Hypo/Hyperthyroidism/ Epilepsy/ Asthma/COPD/ CAD/ Blood transfusions/ Connective tissue disorders (stroke in young)

 -No H/O Major hospitalizations

 -No H/O major surgeries.



PERSONAL HISTORY:

➤Patient is married .

➤Patient takes mixed diet and has a decreased appetite.

➤Bowel and bladder movements are regular 

➤No known allergies .

➤No addictions 

FAMILY HISTORY: Not significant.

GENERAL EXAMINATION:

Patient is drowsy, non coherent and not cooperative.

Vitals:

BP: 150/80 mmHg

PR: 104 bpm

TEMPERATURE:102 degree F

RR:22cpm

Grbs 86 mg/dl

No pallor, icterus, cyanosis, clubbing,lymphadenopathy, pedal edema

 SYSTEMIC EXAMINATION:

 CVS‐ S1 S2 heard, no murmurs

RS‐ Normal vesicular breath sounds heard

P/A - No tenderness, no palpable mass

CNS Examination:

HIGHER MENTAL FUNCTIONS:

DROWSY, NON RESPONSIVE

GCS:E5V2M6

MMSE couldn't be assessed

speech : nil

Behavior : couldn't be assessed 

Memory : couldn't be assessed 

CRANIAL NERVE EXAMINATION:

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

 No Nystagmus 

MOTOR EXAMINATION: 
                               Right                           Left
                           UL          LL                 UL     LL
BULK                   N          N                   N       N
TONE               Hyper    Hyper              N       N
POWER                  Couldn't be assessed.

SUPERFICIAL REFLEXES:

  Corneal           present                          present      
Conjuctival    present                         present

 Plantar          flexor                           mute

DEEP TENDON REFLEXES:

   BICEPS              2+                            1+

   TRICEPS            2+                            1+

 SUPINATOR        2+                            1+
 
   KNEE                 2+                             1+

  ANKLE               2+                             1+

SENSORY EXAMINATION:  

couldn't be assessed 

CEREBELLAR EXAMINATION

couldn't be assessed 

SIGNS OF MENINGEAL IRRITATION: absent

GAIT couldn't be assessed

Cerebellar functions : couldn't be assessed



Provisional diagnosis:

Rt CVA with left hemiplegia with global aphasia

Investigations:
Chest Xray:
MRI:
     


DIAGNOSIS:

Right sided CerebroVascular Accident with left sided Hemiplegia with involvement of area supplied by middle cerebral artery due to embolism .

Plan of management:

1) Ryle 's tube 

2) IV FLUIDS

3) Tab ECOSPRIN 150 MG RT STAT

F/B TAB ECOSPRIN 75 mg RT OD

4)Tab ROSUVASTATIN 40 MG RT STAT

F/B TAB ROSUVASTATIN 20 MG RT OD

5) TAB CLOPIDOGREL 150 Mg RT STAT

F/B TAB CLOPIDOGREL 75 mg RT OD

6) TAB CILNIDIPINE 75 mg. 

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