60Y FEMALE WITH RIGHT HEMIPARESIS

 

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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.

A 60/F K/c/o HTN since 1.5 year & left hemiparesis (right temporo parietal infarct) 1yr back on Rx (antiplatelets) came to casualty at 6:30pm on 16/6/2021 with c/o •Slurring of speech since 1 week,

•Generalized weakness since 1 week,

•Altered sensorium since 15/6/2021 night.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic one and half  year back. Then she was diagnoesd with hypertension for which she was on medication. 1 year back she had slurring of speech and weakness on left side both the limbs for which she got admitted and was treated and on continuous antiplatelet medication. She was fine doing her regular work by herself with little help until 7/6/2021. 

From 7/6/2021 she again had symptoms like •Slurred speech and generalised weakness •Altered sensorium since 15/6/2021 for which she was brought to the causality on 16/6/2021.

No h/o trauma/ head ache / giddiness / LOC / involuntary movements

No h/o fever / vomiting / loose stools

No other complaints

O/E:

pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing: absent

Edema: absent

Lymphadenopathy: absent

VITALS : ( on presentation)

GCS : E2V1M4

Pulse Rate : 150bpm

Blood Pressure : 140/90 mmhg

Sp02: 98% on RA

Temperature: Afebrile

ON SYSTEMIC EXAMINATION:

CVS: 

Thrills: absent

Sounds: S1 S2 + 

Murmurs: not heard

RS: 

BAE + 

NVBS 

PER ABDOMEN: 

soft

No organomegaly 

Bowel sounds heard

CNS:

Power:  Right   Left

  UL        1/5      3/5

  LL         1/5      3/5

Tone:   Right        Left

  UL         N           Increased 

  LL         N            Increased 

Reflexes:

Exaggerated DTR on left side

Normal on right side

B/l plantar extensor

GRBS:116

Na+: 135

K+: 4.1

ABG: 

pH: 7.47

Po2: 91.1

Pco2: 29.1

Hco3-: 21.4

So2: 96%

Provisional Diagnosis:-

RIGHT HEMIPARESIS ( Acute infarct in left lentiform nucleus and head of caudate extending into corona radiata , multiple acute lacunar infarcts in left occipital  and peritrigonal zone) .

K/C/O Left hemiparesis (1y back) 

K/C/O HTN (1.5y back).

INVESTIGATIONS:-

HEMOGRAM

SERUM ELECTROLYTES

PLAIN XRAY CHEST

PT,INR

APTT

PLAIN MRI BRAIN

2D ECHO

TREATMENT PLAN

 Date-16/6/2021

1) Inj. Optineuron 1amp in 100ml NS IV

2) Inj. Pan 40mg OD

Date-17/6/2021

1) Inj. Optineuron 1amp in 100ml NS IV

2) Inj. Pan 40mg OD

3) Tab. Ecospirin av 150/20mg OD

4) Tab. Clopi 75mg OD

5) IV Fluids

6) Inj. Mannitol 100ml IV BD

7) RT feeds.

Date-18/6/2021

1)IV fluids infusion @150 ml/hr both NS and RL

2)Inj. Mannitol 100ml IV BD

3)Inj. Optineuron 1amp in 100ml NS IV

4) Inj. Pan 40mg OD

5) Tab. Ecospirin av 150/20mg OD

6) Tab. Clopi 75mg OD

7) RT feeds.