58 yr female with recurrent Right Hemiparesis


Wednesday, August 30, 2023

58 yr female with Recurrent Rt. Hemiparesis


Hello !This is Srujana yadavalli of eighth sem MBBS.  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. 



A 58 year old female, house-wife by occupation R/O Yadagiri gutta came to the OPD on 29th August 2023 with chief complaints of :

both right upper limb and lower limb weakness since one day

unable to talk (loss of speech) since 4-5 hours 

mouth deviated to left side since 4 hours


HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic one day ago when she developed weakness in both upper and lower limbs of right side and was able to feel senses of both limbs and eat with right upper limb. After 20hrs (one day approx.) patient was unable to speak i.e; sudden loss of speech.

Her mouth was deviated to the left side

No H/O involuntary movements

No H/O Loss of consciousness

No H/O loss of sensation

No H/O up rolling of eyes

No H/O involuntary passage of urine and feces

No H/O tremors

No H/O fever

No H/O trauma to head

No H/O sleep disturbances


Her daily routine was to  wake up at 6: 30 am, drink plain milk(without sugar) at 7:00 am, breakfast (4 idly + karam podi ) at 8:00 am. She used to have her lunch as rice and curry (less spicy and less /no salt)  at 1: 00 pm and some milk(without sugar) at 5 :00 pm . She usually has her dinner as rice with curry (less spicy and less /no salt) at 9:00pm and goes to bed by 9:30 pm.

The patient was able to walk with the help of support for last 2 years and used to speak normally before loosing her speech 5 hours ago.


PAST HISTORY:

K/C/O HTN since May 2021. On unknown medication (2.5mg ???)

K/C/O CVA- Right hemiparesis since 2 yrs. course completed (unknown medication)

History from May 2021 

While this absolutely normal female is travelling on a two wheeler for 15km and when her destination has arrived , she was not able to get down the vehicle and felt tingling sensation with numbness in her right upper and lower limb. She was taken home and those symptoms didn't subside even after 6 hours, didn't perceive sensations, able to talk normally, no mouth deviation, no involuntary movements, no up rolling of lids, no incontinence of urine or feces, no loss of consciousness, no trauma to head, no tremors . She was rushed  to a local hospital where she was diagnosed PARALYSIS and asked them to go to a higher hospital(Gandhi govt). She was admitted for 15 days in hospital and given medications. MRI/ CT?? was taken which was interpret to family as bleeding hemorrhage in brain?? While Discharge they were told that the size of hemorrhage has decreased and bleeding stopped and asked to follow up a course of drugs ( MVT & ?? & ??) and advised to go for physiotherapy for 2-3 months.(taken)


She was also diagnosed with Hypertension and given medications which she is still continuing now. 

N/K/O DM, CAD, TB, Epilepsy, Asthma, Thyroid,..

 

SURGICAL HISTORY:

Patella surgery 7 yrs ago

LSCS 28yrs ago


FAMILY HISTORY:

Not significant


PERSONAL HISTORY:

Married

House- wife

Diet: mixed (less spicy, less salt, less oil, no sugar, drinks only hot water)

Appetite: normal

Bowel & bladder movements: regular

Sleep: adequate, not disturbed

Addictions: none

Allergies: no known


MENSTRUAL HISTORY: Menopause 10yrs ago

OBSTETRIC HISTORY:  G5P4L5

First preg.: FTNVD Male alive and healthy

Second preg.: FTNVD Twin females alive and healthy

Third preg.: FTNVD Female alive and healthy

Fourth preg.: FTLSCS Male alive and healthy


PHYSICAL EXAMINATION:

GENERAL:

Patient is conscious coherent and cooperative to time place and person.

Ht: 155cm         Wt: 50kg

Pallor: no

Icterus: no

Clubbing: no

Cyanosis: no

Lymphadenopathy: no

Edema: no


Vitals: BP: 110/80mmHg

Temp: Afebrile

PR: 102 bpm

RR: 24 cpm

SpO2: 98%

GRBS: 170 mg%


SYSTEMIC EXAMINATION:

--CVS: S1 S2 heard

no thrills

no murmurs

RS: no dyspnoea

no wheeze

central position of trachea

normal vesicular breath sounds +

--ABDOMEN: Shape: scaphoid

no tenderness

normal hernial orifices

no free fluid

no bruits

liver and spleen not palpable

--CNS: altered sensorium

incoherent speech

no neck stiffness

kernig's sign negative

cranial nerves, motor system , sensory system: intact, normal

Glasgow scale: E4V1M6

Cerebellar signs- unable to elicit









INVESTIGATIONS:

29-8-23



30-3-23

















PROVISIONAL DIAGNOSIS:

RECURRENT CVA 

with HEMORRHAGIC INFARCT in parieto-occipital region

with K/C/O HTN since 2 yrs

BROCA'S APHASIA??


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