62 Years old Female with Paralysis of Left upper and lower limbs

62 years old female with paralysis of left upper and lower limbs

November 7th 2022

 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 Elog book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment .

Chief Complaint:

Left upper and lower limb paralysis since one day

History of presenting illness

Patient was asymptomatic 1 week ago (till last sunday)and going to her work till sunday,and stopped working since sunday as she developed tingling of left upper limb and lower limbs and when she was about to wakeup in the early morning (4:00 am)for washroom,she was unable to get up from the bed and noticed weakness of left sided upper and lower limbs associated with tingling sensation,the very next day local RMP doctor noticed high recordings of BP and gave her anti hypertensives and advised her to higher centre and she came to OPD yesterday with complaints of unable to move  left upper and lower limbs
No c/o fever,vomitings,loose stools,giddiness 
No c/o slurring of speech,and no drooling of saliva.
No c/o chestpain,palpitations,syncopal attacks.

Past history:
Not a known case of HTN,DM,TB,ASTHMA,CAD,EPILEPSY .

Personal history:
Diet - mixed
Appetite - normal
sleep - adequate
Bowel and Bladder movements -regular
No known allergies
Addictions:Tobacco smoker since 40years
Alcoholic since 40years,(90ml)once in every 10days

Family History:
Not Significant

Drug history : 

No significant drug history

General examination :
Patient is conscious ,coherent,cooperative and was well oriented to time ,place and person at the time of examination

She is moderately built and well nourished.
Pallor - absent
Icterus - absent
Cyanosis - absent 
Clubbing - absent
lymphadenopathy - absent
Pedal edema - absent

Vitals at admission:
Bp:130/80mmHg
PR:88bpm
Cvs:s1 and S2 heard,No murmurs
RS: NVBS,BAE PRESENT
Abdomen:SOFT,NON TENDER

CNS Examination

Higher mental functions:

Oriented to time,place,person

Memory :  Immediate,recent, remote intact

Speech: Normal

No delusions or hallucination

Cranial nerves: 

1- not tested

2- Pupillary reflex present

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

7-Normal, wrinking of forehead seen, able to blow up cheeks

8- Normal hearing


Motor examination:

Tone - Decreased in left upper and lower limb

Power-.                     Right    Left

             Upper limb   4/5       2/5

              Lower limb   4/5      3/5

Reflexes :

Biceps: Right++

               Left: absent

Triceps: Right++

               Left: absent

Supinator: Right++

               Left: absent

Knee: Right: ++

           Left: Absent

Ankle: Right: ++

             Left: Absent

Plantar: Right : Flexion of great toe

               Left: Extension

Cerebellum examination:

Able to do finger nose test.

Not able to do  dysdiadokinesia 

Gait: did not walk due to weakness

Investigations:

Hemogram


Lipid profile


Liver function tests


Random blood sugar 


Blood urea


Serum creatinine 

Serum Electrolytes 


X ray 

ECG

Color doppler 2d Echo



Diagnosis

Acute Ischemic Stroke - Acute infarct in right occipital lobe,right posteriotemporal lobe and right thalamus- PCA territory

Treatment:
T.Ecospirin 150mg po od
T.clopitab 75 mg po od
T.atorvas 20 mg po od
T.pregaba M 75mg po od 
Vitals monitoring 4th hrly









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