Hemiplegia
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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. 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.
A 62 year old female patient from miryalaguda presented to casualty with chief complaints of sudden weakness of left upper limb and lower limb since 4 days
HOPI: patient was apparently asymptomatic 4 days ago , she used to get up early in the morning at 7O clock ,used to do her daily activities such as cooking,washing clothes etc .On 3/11/21 at night ,she was applying ointment to her painful knees as usual, at 11pm she has difficulty to got up to go to washroom and she urinated on her bed itself.Next morning , on 4/11/21 patient relatives have seen her having difficulty in getting her up and took to the hospital on 5/11/21. The weakness is sudden and non progressive .She was a hardcore worker , she was a farmer ,digger ,labour worker,but she stopped her work 6 years ago , due to knee pain and hip pain .From past 1 year the pains are aggravated , her gait also changed due to the pain (antalgic gait) and walking with the help of stick, the pain is more in left knee and hip ,more in night , unable to sleep due to the pain and using ayurvedic medicines for pain. She has 3 daughters and two sons , she got her hysterectomy done at age of 30yrs due to heavy menses and fibroid.
H/o slurred speeech , it had been progressive,however she was able to understand the words of her daughter,use appropriate words while talking but fluency is reduced(dysarthria?) and she spells ' da' instead of 'na',could identify objects .H/o talking inappropriately
There is slight deviation of mouth to right side .
H/o urinary Incontinence (paracentral lobule involvement?)
H/o tenderness of joints and pain increased on movement of joint.
H/o vomiting on 7/11/21 non projectile nonbilious.
No history of headache, nausea ,vomiting, aura(chronic meningitis)
No h/o loss of consciousness (to rule out brainstem Ras)
No H/o transient loss of vision( to rule out TIA)
No H/o fever,nightsweats,weightloss
No H/o head/ spine trauma
No H/o involuntary movements,uprolling of eyes,loss of consciousness, (hemorrhagic and embolic)
No H/o palpitations and breathlessness( atrial fibrillation)
No h/o dental or surgical procedures
H/o fever( venous thrombosis)
No h/o double vision(3,4,6 cranial nerves)
No h/o vertigo ,tinnitus( 8)
No h/o difficulty in swallowing ,nasal regurgitation, hoarseness of voice (9,10)
No h/o altered sensorium and behavioural changes
PAST HISTORY:
No h/o similar complaints in the past
No h/o hypertension, diabetes ( raised sugar levels after admission),epilepsy, TB,COPD,RHD,PVD.
H/o hysterectomy 20 years back
No h/o allergies
DRUG HISTORY:
Using NSAIDs and ayurvedic medicines for her hip and leg pain for 3 years.
H/o synovial fluid aspiration 3 times in past one year , pain is relieved.
FAMILY HISTORY:no h/o similar complaints in family , no cva in family
Personal history:
Mixed diet( if veg-b12def- homocysteinuria?)
Has normal appetite
Sleep inadequate due to pains
Regular bowel and bladder
No h/o smoking ,alcohol
EXAMINATION
general examination:
DOE: 6/11/21 8PM
Patient is conscious,coherent and cooperative oriented to time place and person, but little drowsy.
Patient lying supine on the bed comfortable
She was moderately built and moderately nourished
VITALS:
BP: 140/80 on left arm
Right arm - not checked due to saline
Pulse rate : 74pm on right side.regualr rhythm, normal volume and character
Peripheral pulses are felt with equal intensities, no radiofemoral delay,arterial wall is not thickened( probably).
RR: thoracoabdominal type, 20cpm, depth is normal (abdomen respiration is slightly bounding to right side)
Temperature: not checked
No pallor, icterus, cyanosis,clubbing, generalized lymphadenopathy, pedal edema
Slight swelling behind the ears due to fluids
No nystagmus,squint,ptosis
No engorged neck veins
No evidence of xanthomas
Skin ecchymosis in cubital fossa on left arm and dorsal surface on right palm,due to placement of catheter.
1.HIGHER MENTAL FUNCTIONS:
Conscious, coherent, cooperative
Appearence and behaviour:
Emotionally stable
Recent,immediate, remote memory intact
Speech: comprehension normal, fluency reduced, repetition sometimes,
Right handed individual
2.CRANIAL NERVE EXAMINATION
Olfactory: normal
Optic:
visual field: cannot be assessed she cannot see left view
Visual acuity: CF
Colour vision : cannot be assessed
Pupil: cannot be assessed, as she is closing eyes while passing light ( photophobia)
3,4,6: normal ocular motility in all directions.
Accommodation
Light reflex
Trigeminal: normal sensory ,motor
Facial nerve:
Forehead wrinkling present
Able to close her eyes
Able to blow ( not fully)
Angle of mouth slightly deviated to right
8nerve: decreased hearing ,no nystagmus
9 and 10 nerve:normal
11: scm and trapezius- normal cannot turn her head extremely to left side!
12: no deviation of tongue, no fasiculations
IMPRESSION:
Left Umn facial palsy?
MOTOR EXAMINATION
Attitude: in supine position,both upper and lower limb extended
Nutrition
U/L R L
Arm -23 cm 24cm
Forearm-6.8inches 7inches
L/L
Thigh: 8.8inch 8.8inch
Calf: 15 inch 15inch
No atrophy noted
Tone:
Right left
Ul:Flexors normal increased
Extensors normal reduced
Ll: flexors normal reduced
Extensors normal increased
In elbow supported wrist joint makes obtuse angle
Impression : hypertonia spasticity
Power: right left
Shoulder:
flexion : 4/5 1
Extension 5/5 1
Abduction 5/5 1
Adduction 5/5 1
Internal rotation 5/5 1
External rotation 5/5 1
Elbow:
Flexion:5/5
Extension:5/5
Wrist:5/5
Flexion:5/5
Extension:5/5
Abduction :5/5
adduction:5/5
Hip
Flexion:5/5
Extension5/5
Abduction:4/5
Adduction4/5
Internal rotation:5/5
External rotation5/5
Knee
Flexion :5/5 3/5
Extension5/5 2/5
Ankle
Plantarflexion:5/5
Dorsiflexion5/5
Toe
Movements:5/5
Impression : left upper limb and lower limb cannot move against gravity.
REFLEXES: right left
Corneal N N
Conjunctival N N
Abdominal: present absent
Plantar: flexor extensor response
DEEP REFLEXES:
Biceps : 2+ 3+
Triceps : 2+ 3+
Knee : 2+ 3+
Ankle: 1+ 3+
No clonus
IMPRESSION: absent superficial reflexes and exaggerated deep tendon reflexes on left side
SENSORY FUNCTIONS
SPINOTHALAMIC TRACT
Pain , temperature ,presure- intact in all limbs
Posterior column:
Fine touch, vibration and proprioception are intact
CEREBELLAR FUNCTIONS:
Titubation: absent
Nystagmus: absent
Dysmetria:absent
Dysadeadochokinesia: absent
Intention tremor:absent
Impression:no signs of cerebellar dysfunction.
CVS:
inspection:precordium is normal
Palpation: apex beat : at 5th intercoastal space 2cm away from midclavicular line
No palpable thrills or heaves
Auscultation:s1, s2 heard, no murmurs
Respiratory system:
inspection : normal
Palpation:position of trachea:central
And expansion: normal
PERCussion:
Auscultation: bilateral vesicular breath sounds are heard
Perabdomen:inspection: normal
Palpation: Soft , non tender
No organomegaly
Percussion:no fluid thrill and shifting dullness
Auscultation:bowel sounds are heard
INVESTIGATIONs:
MRI BRAIN
Impression:multiple acute infarcts in right frontal lobe parasagittal region and genu of corpus callosum - ACA territory infarct
Old lacunar infarcts in bilateral basal ganglia ,left thalamus and right corona radiata
ECG:
IMPRESSION:
Left axis deviation
2D ECHO of heart:
Left ventricular hypertrophy
Diastolic dysfunction
Other investigations CBP, RFT, LFT
TREATMENT:
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