60 F, Altered sensorium, Quadriparesis

 

June 17th 2021.

This is an 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.

A 60 year old female presented with complaints of slurring of speech, generalised weakness, and altered sensorium.

K.Medha Reddy, 8th semester

Roll No: 51

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 60 year old female came to the casualty at 6:30 PM with C/O 

• slurring of speech - 1 week
• generalised weakness - 1 week
• altered sensorium - from yesterday night.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 1 year back. Then she developed:

• Slurring of speech and generalised weakness - 1week which was sudden in onset and gradually progressive.
• Altered sensorium from last night (as in on 15th night).

NEGATIVE HISTORY:

No H/O headache

No H/O giddeness, or loss of consciousness

No H/O involuntary movements

No H/O fever, vomitings ans loose stools.

No other relevant complaints.

PAST HISTORY:

Had similar complaints and same presentation of symptoms in the past, 1year ago for which she is on antiplatelet medication.(Diagnosed as Left hemiparesis caused due to right temporo parietal infarct)

K/c/o Hypertension since 1½ year and is on medication.

No H/O DM/ Thyroid abnormalities/ TB/ Asthma/ Epilepsy.

PERSONAL HISTORY:

Diet: Mixed

Appetite: Normal

Sleep: Adequate

Bowel and bladder habits: Regular

Addictions : Absent

No other drug history

No H/O Allergies (drug and food)

ON GENREAL EXAMINATION:

• moderately built and nourished
• pallor: absent
• Icterus: absent
• Cyanosis: absent
• Clubbing: absent
• Edema: absent
• Lymphadenopathy: absent

• VITALS : ( on presentation)

• GCS : E2V1M4
• Pulse Rate : 150bpm
• Blood Pressure : 140/90 mmhg
• Sp02: 98% on RA
• Temperature: Afebrile

ON SYSTEMIC EXAMINATION:

CVS: 

Thrills: absent

Sounds: S1 S2 + 

Murmurs: not heard

RS: 

BAE + 

NVBS 

wheeze +

PER ABDOMEN: 

soft

No organomegaly seen

Bowel sounds heard

CNS:

Power: 

spontaneously moving left UL & LL

No spontaneous movements of right UL & LL

Tone:

Hypertonia on left side

Normal to hypotonia on right side

Exaggerated DTR on left side

Normal on right side

B/L plantar reflex : extensor

INVESTIGATIONS:

CBP:

GRBS : 116

URINE EXAMINATION:

Na+: 135

K+: 4.1

ABG: 

pH: 7.47

Po2: 91.1

Pco2: 29.1

Hco3-: 21.4

So2: 96%

ECG:

X RAY:

Provisional Dx:

Altered sensorium under evaluation

Quad riparesis ?

Old left sided CVA 

New onset right CVA

PLAN : MRI

TREATMENT:

ON DAY 1 OF ADMISSION: (17th June)

No new complaints

Patient is conscious, coherent and cooperative.

ON EXAMINATION:

Power : 

UL: 1/5 (on both sides)

LL: 3/5 (on both sides)

INVESTIGATIONS: 

ECG:

 

MRI:

2D ECHO WITH DOPPLER STUDY:

DIAGNOSIS:

Old Left CVA : Right temporo-parietal infarct

New Right CVA : Left MCA Territory infarct with Aphasia. 

TREATMENT: