A 50 year old female patient with slurred speech and weakness of Right lower limb.

This is an a 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.


CASE:

  • A 50 year old female patient brought to the casualty complaining of slurred speech and and weakness of Right lower limb since 1 day.

History of presenting illness:

  • Patient was apparently asymptomatic 1 day  back then she complained of headache,tingling and numbness of head and had 7 -8 episodes of vomiting -non projectile,bilious, watery with food particles as content .
  • Patient also developed weakness of Right lower limb insidious in onset and gradually progressive with difficulty in walking. 
  • Headache localised to left side lasted for 2 to 3 hours which subsided itself.
  • Patient developed slurring of speech since then .
  • No H/O trauma,fever .
  • No H/O chestpain,SOB, blurring of vision,diplopia,
  • deviation of mouth,frothing from mouth,seizures,loss of consciousness .
  Past history:
  • Patient is a known case of DM II since 6 years on medication T.Metformin 1000 mg and T.Glimiperide 2mg OD .
  • K/C/O hypothyroidism since 6 yrs on medication T.Thyronorm 100 mcg OD .
  • Not a known case of Hypertension, asthma epilepsy, CAD,TB,CVA .

Personal history:

  • Diet-mixed 
  • Appetite-normal 
  • Sleep-adequate 
  • Bowel and bladder movements-regular
  • Addictions- Toddy and alcohol consumption occasionally .

Family history:

  • Not significant 
  • General examination:
  • Patient is conscious,coherent, cooperative Moderately nourished and  built .
  • No pallor,Icterus, cyanosis, clubbing lymphadenopathy, edema
Vitals:

  • Afebrile
  • BP-Right Brachial artery 120/90
  • Left Brachial Artery 150/100 
  • PR-80bpm
  • RR-16cpm
  • Grbs-469mg/dl



Systemic examination:

  • Central nervous system:
  • Oriented to time,place,person
  • Speech: slurred
  • Cranial nerves: 

1-intact
2- vision: normal
3-ptosis of left eye 
4,6- normal
5-normal( muscles of mastication+sensations of face)
7- no deviation of mouth,ability of closure of right upper eye lid is decreased.unable to raise eyebrows,can't close her eyes completely.
8- normal 
9,,11,12-normal
10 - difficulty in swallowing 



  • Motor- tone -normal

Power- upper limb            lower limbs 

Right.         4/5                      4/5

Left            4/5                       4/5



  • Reflexes :         Right                Left 

biceps:             2+                       2+
Triceps:            2+                      2+
Supinator:        -                           -
Knee:                 2+                     2+
Ankle:                -                          -
Plantar: withdrawal flexion
Sensory examination:


  • Spinothalamic tract: Right          left

     Crude touch            intact            intact    

     Pain                        intact              intact 

     Temperature           intact           intact 

  • Posterior column:    

      Fine touch          intact               intact            

     Vibration.            intact              intact 

           
  • Cortical:

     Graphesthesia      +              +

     Stereognosis        +                +

     tactile sensation   +             +

Cerebellar signs 
        
  • Ataxic gait 
  •   Finger nose test - positive with left hand
  •  Past pointing
Gait video

https://youtube.com/shorts/FGox4CXU5jY?feature=share4


Provisional diagnosis:

Acute CVA with chronic lacunar infarct .



Treatment: 

1. Tab. ECOSPIRIN 75 mg  po/hs 9 pm 
2.Tab .Glimiperide 2 mg PO/OD 
3.Tab.Metformin 1000 mg PO/OD
4.Tab.Thyronorm 100mcg PO/OD

  • Opthalmology Referral I/V/O Diabetic Retinopathic Changes .
  • 3 Dot and blot haemorrhages seen in superior quadrant of Left eye suggestive of Mild NPDR changes in left eye .
Advised :
Fundoscopy every 6 months .
Strict Glycemic control .

 Investigations:

CBP:

  • Haemoglobin 11.5 gm/dl
  • TLC:6500cells/cu mm
  • Platelet:2.36 lakhs/cumm 



RFT :

  • S. Creat: 1.1mg/dl
  • Blood urea: 27mg/dl
  • Na: 143 
  • Cl:98
  • K:3.6 
  • LFT:
  • T. Bilirubin:0.77
  • D. Bilirubin:0.23
  • ALP: 244
  • AST:22
  • Albumin: 3.7



Rbs:424 mg/dl 

Hba1c: 7.4g%
Urine for ketone bodies - negative 
Uric acid -2.7 
CUE: 
ALBUMIN +
SUGARS  +++

10/07/2023

Ward : Medical ward 
Unit : 6
DOA : 9/7/23


S: 
No Fresh Complaints 


O:
Patient is conscious coherent and cooperative 

No icterus,cyanosis,clubbing,
lymphadenopathy

Bp-160/90mmHg
Pr- 72 bpm
Temperature - Afebrile 
Rr- 16cpm
Spo2- 99% on RA
Grbs- 328mg/dl @8am
 

CVS-S1,S2 heard ,no murmurs
RS- BAE present 
NVBS 
CNS-
Pupils- B/L NSRL
Tone  
           UL.               LL 
R.        Normal       Normal 
L.        Normal        Normal 
 
Tone 
 R.      4/5                4/5 
 L.       4/5               4/5
                   
Deep tendon reflexes:

Biceps:         +2       +2

Triceps:        +2       +2

Supinator:.     -         -

Knee:            +2       +2

Ankle:           -           -

Plantar:    flexor      flexor 

P/A- Soft, NT

A:ACUTE CVA with lacunar infarct .
K/c/o DM2 since 6 yrs 
K/c/o hypothyroidism since 6 yrs 

P:
1.RT FEEDS. 200 ml milk 4 th hourly 
2.T.Metformin 1000 mg RT/OD 
    T.GLIMPERIDE 2 MG RT/OD 
3.T.THYRONORM 100 MCG RT/OD

11/07/2023

Ward : Medical ward 
Unit : 6
DOA : 9/7/23

S: 
No fever spikes 
Speech improved 
No Fresh Complaints 


O:
Patient is conscious coherent and cooperative 

No icterus,cyanosis,clubbing,
lymphadenopathy

Bp-130/90mmHg
Pr- 78 bpm
Temperature - Afebrile 
Rr- 16cpm
Spo2- 99% on RA
Grbs- 218mg/dl @8am
 

CVS-S1,S2 heard ,no murmurs
RS- BAE present 
NVBS 
CNS-
Pupils- B/L NSRL
Tone  
           UL.               LL 
R.        Normal       Normal 
L.        Normal        Normal 
 
Tone 
 R.      4/5                4/5 
 L.       4/5               4/5
                   
Deep tendon reflexes:

Biceps:         +2       +2

Triceps:        +2       +2

Supinator:.     -         -

Knee:            +2       +2

Ankle:           -           -

Plantar:    flexor      flexor 

P/A- Soft, NT

A:ACUTE CVA with lacunar infarct .
K/c/o DM2 since 6 yrs 
K/c/o hypothyroidism since 6 yrs 

P:
1. Allow soft diet
2.Inj Optineuron 1 amp in 500 ml NS /IV/OD
3.T.Metformin 1000 mg RT/OD 
    T.GLIMPERIDE 2 MG RT/OD 
4.T.THYRONORM 100 MCG RT/OD


12/07/2023

Ward : Medical ward 
Unit : 6
DOA : 9/7/23


S: 
No fever spikes 
Speech improved 
Complaints of throat pain while swallowing 


O:
Patient is conscious coherent and cooperative 

No icterus,cyanosis,clubbing,
lymphadenopathy

Bp-160/100mmHg
Pr- 76 bpm
Temperature - Afebrile 
Rr- 16cpm
Spo2- 99% on RA

 
CVS-S1,S2 heard ,no murmurs
RS- BAE present 
NVBS 
CNS-
Pupils- B/L NSRL
Tone  
           UL.               LL 
R.        Normal       Normal 
L.        Normal        Normal 
 
Tone 
 R.      4/5                4/5 
 L.       4/5               4/5
                   
Deep tendon reflexes:

Biceps:         +2       +2

Triceps:        +2       +2

Supinator:.     -         -

Knee:            +2       +2

Ankle:           -           -

Plantar:    flexor      flexor 

P/A- Soft, NT

A:ACUTE CVA with lacunar infarct .
K/c/o DM2 since 6 yrs 
K/c/o hypothyroidism since 6 yrs 

P:
1. Allow soft diet
2.Inj Optineuron 1 amp in 500 ml NS /IV/OD
3.T.Metformin 1000 mg RT/OD 
    T.GLIMPERIDE 2 MG RT/OD 
4.T.THYRONORM 100 MCG RT/OD
5.T.ATORVAS-CV 20/75 mg PO/HS



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