Gm online assessment

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:

Difficulty in moving left upper limbs and lower limbs since 3 days.

Weakness in right and left upper limbs and lower limbs since 3 days

Inability to speak since 3 days.

HOPI

Patient was apparently asymptomatic 3 days back she developed weakness in Saturday in left upper and lower limbs which was sudden in onset , gradually progressed and is completely unable to move since 3 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 2 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.

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:          couldnt be assesssed

  SUPERFICIAL REFLEXES:

  Corneal          present        present      

 CONJUNCTIVAL    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 x-ray:

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