A 55 year old female with difficulty in speaking
This is 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 comments on comment box is welcome.
I've 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 a diagnosis and treatment plan.
Following is the view of my case:
CHIEF COMPLAINTS:
A 55 year old female , daily wage labourer,right handed from kondagadapa came with chief complaints of difficulty in speech
Patient was apparently asymptomatic 35 years ago then patient husband noticed sudden loss of consciousness followed by stiffening of both limbs which is flexion of upper limbs and lower limbs with fisting of hands not associated with up rolling of eyes, frothing in mouth , urinary and fecal incontinence lasted for 10 mins during pregnancy of her second child( trimester?) and her pregnancy was uneventful , normal vaginal delivery at home , since then she has frequent seizure episodes , which is one once a month not compliant on medication preceded by emotional distress and reduced intake of food.
H/o fall 8 years ago due to seizure episode sustained a head open wound injury on left side due to a nail (8-10 stitches),and taken to hospital, for which MRI has done , doctors said that she has peanut sized lesion in left cerebral hemispheres and she had incoherent speech after the attack slowly regained after 1 month with the use of some unknown medication
H/o similar episode 7 years back recovered within 10 days .
in between episodes ,she still continues having seizures once/twice in amonth
3rd episode
on thursday night she told her husband that she is not feeling well before going to bed , on friday morning at 5:00 am her husband tried to wake her up ,but she didnt respond and she is stiff with upper limbs flexion and lower limbs extended and had snoring ,she wokeup after doctor checking her ,she has movements of staring and short period of memory loss and unable to identify her own family members and after a while, she recognized them but she forgot her their names and object names and using monosyllables to express what she wanted , she is struggling to speak full sentences and repeating the same word, pointed to a bottle of water , she cant name it , but if we say the use of it, she can name it. There is latency of commands .
PAST HISTORY: H/o TB on ATT for 6 months .
Not a known case of Hypertension, diabetes,asthma.
Hysterectomy 10 years ago
PERSONAL HISTORY:DIET: Mixed
appetite: decreased
bowel and bladder : regular
sleep adequate
addictions: none
DAILY ROUTINE:
at 5:00 she wakes up does cooking , clean the house, at 9 /10 am she eats breakfast( ,drink chai, she goes to kirana shop and sells items , at 1 PM she eats lunch (mixed diet),go to paddy field some times and 9pm she eats dinner and sleeps.
Before the injury ,she went to paddy fields and did heavy work , after injury as her seizure episodes are increasing , she limited her activities .
she has hlo recuurentepisodes of headache mostly on left side and radiating to neck.
FAMILY HISTORY:
NO significant family history
TREATMENT HISTORY: on ATT till november , occasionally on unknown medication for seizures .
GENERAL PHYSICAL EXAMINATION:
patient is examined in well lit room,
patient is conscious and cooperative but not coherent not oriented to time and place.
She was poorly built and well nourished
VITALS:
BP: 110/70mmHg on right arm
Pulse rate : 92bpm on right side.regualr rhythm, normal volume and character
Peripheral pulses are felt with equal intensities, no radiofemoral delay,arterial wall is not thickened.
RR: thoracoabdominal type, 20cpm, depth is normal
Temperature: not checked
No pallor, icterus, cyanosis,clubbing, generalized lymphadenopathy, pedal edema
.jpg)
https://youtu.be/t2JeYnBiWko
No nystagmus,squint,ptosis
No engorged neck veins
No evidence of xanthomas
1.HIGHER MENTAL FUNCTIONS:
Conscious, and , cooperative , has long latency to commands.
Appearence and behaviour: u hygienic and smiling for each response.
Emotionally stable
Recent,immediate, remote memory intact
Speech: fluency normal, comprehension unaffected, repetition of words present
Calculation cannot be elicited
Right handed individual
https://youtube.com/shorts/Zbel3GqlVOk?feature=share
2.CRANIAL NERVE EXAMINATION
Olfactory: normal
Optic: normal
visual field: cannot be assessed
Colour vision : cannot be assessed
Pupil: NSRL
3,4,6: normal ocular motility in all directions
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 left
8nerve: normal hearing no nystagmus
9 and 10 nerve:normal
11: scm and trapezius- normal
12: deviation of tongue to right side no fasiculations
IMPRESSION:
Left Umn facial palsy
Left hypoglossal nerve palsy umn type
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 normal
Extensors normal normal
Ll: flexors normal normal
Extensors normal normal
Power: right left
Shoulder:
flexion : 4/5 5/5
Extension 5/5 5/5
Abduction 5/5 5/5
Adduction 5/5 5/5
Internal rotation 5/5 5/5
External rotation 5/5 5/5
Elbow: both limbs
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 5/5
Extension5/5 5/5
Ankle
Plantarflexion:5/5
Dorsiflexion5/5
Toe
Movements:5/5
REFLEXES: right left
Corneal N N
Conjunctival N N
Abdominal: present present
Plantar: flexor flexor
DEEP REFLEXES:
Biceps : 3+ 2+
Triceps : 3+ 2+
Knee : +++ 3+
https://youtube.com/shorts/0IuNamfxke4?feature=share
Ankle: ++ ++
No clonus
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: not able to perform
https://youtube.com/shorts/gFIQwCzxhe4?feature=share
Intention tremor:absent
Impression:no signs of cerebellar dysfunction.
AUTONOMIC FUNCTION:normal
CVS:
inspection:precordium is normal
Palpation: apex beat : at 5th intercoastal space in midclavicular line perceived I left lateral position
No palpable thrills or heaves
Auscultation:s1, s2 heard, no murmurs
Respiratory system:
inspection : 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
PER ABDOMEN :
inspection: normal
Palpation: Soft , non tender
No organomegaly
Percussion:no fluid thrill and shifting dullness
Auscultation:bowel sounds are heard
INVESTIGATIONS:
MRI BRAIN:
PATHOLOGICAL :
ischemic infarcts due to thrombosis /emboli
Comments
Post a Comment