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 also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
CASE PRESENTATION:
A 60year old female resident of bollaram , farmer by occupation came to the hospital with the chief complaints of Drooling of saliva with slurring of speech since 7 days . weakness in the left upper and lower limb with deviation of mouth to right side since 6 days.
HOPI:
Patient was apparently asymptomatic 4-5 years back , then she developed tingling and numbness sensation Associatedw intermittent headache , neck pain, giddiness for which she had been to a hosiptal diagnosed with hypertension and was under medication (Tab ATEN 50mg od)
Suddenly she had deviation of mouth to right side with drooling of saliva. Associated with slurring of speech in the morning at 8:,00 am during breakfast 1 week back
.
Then weakness of left upper limb since 6 days for which she tried lifting objects with left upper limb to regain her strength in that affected limb
Weakness of left lower limb since 4 days. Then after she was taken to nearby hospital where her BP was around 190/110 and CT scan was done showing an acute infarct in the right corona radiata and treatment was given.
Inability to use her limbs which was sudden in onset with progressive in nature.
H/o pain in left hip joint and elbow joint.
No h/o trauma.
No h/o fever, diarrhoea, vomitings, cough, shortness of breath, chestpain, orthopnea, paroxysmal nocturnal adyspnea,
No h/o involuntary movements, neck stiffness, wasting or thinning of muscles.
PAST HISTORY:
K/c/o hypertension since 4-5 years and is on tab. ATEN 50mg.
No h/o diabetes mellitus, epilepsy , bronchial asthma, chronic heart and kidney diseases, tuberculosis, thyroid disorders.
No previous surgeries and blood transfusion.
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements: regular.
No addictions.
FAMILY HISTORY:
No significant family history.
DRUG HISTORY:
Not allergic to any known drugs.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative.
Moderately built and moderately nourished.
No signs of pallor, icterus, cyanosis , clubbing, kilonychia, generalised lymphadenopathy, bilateral pedal edema.
VITALS:
Temperature: afebrile
Pulse rate: 80 beats per min
BP: 140/ 100 mm of hg
RR: 22 cycles per min.
Sp02 : 99% at room temperature
GRBS: 127 mg/dl.
SYSTEMIC EXAMINATION:
-CNS:
- Higher mental functions: conscious and alert with slurred speech.
- Spinomotor : no wasting/ thinning of muscles. No pain, fatigue and fasciculations.
Right. Left.
Bulk :. Normal. Normal
Tone:
Upper limb:. Normal. Decreased
Lower limb:. Normal. Decreased
Power:
Upper limb:. 4+/5. 2</5
Lower limb:. 4+/5. 3/5
-Motor system
Reflexes:
Superficial reflexes: normal
Deep tendon reflexes:
Biceps:. +. ++
Triceps:. +. ++
Supinator:. -. +
Knee:. -. ++
Ankle:. -. +
Plantar:. Withdrawal. Extensor
-Sensory system: right. Left
Fine touch +. -
Vibration. +. -
Position sense +. -
Crude touch. +. +
pain and temperature +. +
-Cranial nerve examination:
Vll: Deviation of mouth to right side.
Drooling of saliva present
Able to close eyes.
frowning present on both sides on forehead
Others cranial nerves: normal.
-ANS: Able to feel bladder fullness, regular bladder movements. No sweating and palpitations.
- Meninges: no fever, headache, neck stiffness, nausea and vomitings.
-PERABDOMINAL EXAMINATION:
Shape of abdomen: scaphoid
No tenderness and local rise of temperature.
No palpable masses.
Hernial orifices normal.
No free fluid and bruit.
Liver and spleen : not palpable.
Bowel sounds: normally heard.
-RESPIRATORY SYSTEM:
Position of trachea: normal
No wheeze and dyspnea.
Bilateral air entry present.
Normal vesicular breath sounds heard.
No adventitious sounds.
-CVS:
S1 and S2 heard.
No murmurs.
-Based on above findings, the following investigations were sent.
