50 year old female with slurred speech and right lower limb weakness


This is an a 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. This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome. 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.


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-> A 50 year old female patient brought to the casualty complaining of slurred speech and and weakness of Right lower limb since 1 day.

-> HOPI

Patient was apparently asymptomatic 1 day  back then she complained of headache,tingling and numbness of head. 

The patient had 7 -8 episodes of vomiting -non projectile,bilious, watery with food particles as content .

Patient also developed weakness of Right lower limb insidious in onset and gradually progressive with difficulty in walking. 

Headache localised to left side lasted for 2 to 3 hours. It then subsided spontaneously.

Patient developed slurring of speech since then .

No H/O trauma,fever .
No H/O chestpain,SOB, blurring of vision,diplopia,
deviation of mouth,frothing from mouth,seizures,loss of consciousness.

-> Past History 

Patient is a known case of DM II since 6 years on medication T.Metformin 1000 mg and T.Glimiperide 2mg OD .

Patient is a known case of hypothyroidism since 6 yrs on medication Thyronorm 100 mcg OD .

Not a known case of Hypertension, asthma epilepsy, CAD,TB,CVA.

-> Personal history:

Diet-mixed 

Appetite-normal 

Sleep-adequate 

Bowel and bladder movements-regular 

Addictions- Toddy and alcohol consumption occasionally 

-> Family history:

Not significant 

-> GENERAL EXAMINATION 

Patient is conscious,coherent, cooperative, well oriented to time and place. 

Patient is moderately nourished and built.

No pallor,Icterus, cyanosis, clubbing lymphadenopathy, pedal oedema. 

Vitals:

Afebrile
BP-Right Brachial artery 120/90
Left Brachial Artery 150/100 
PR-80bpm
RR-16cpm
Grbs-469mg/dl

-> SYSTEMIC EXAMINATION 

CNS EXAMINATION 

• Oriented to time,place,person

• Speech: slurred

• Cranial nerves: 

1-intact

2- vision: normal

3- ptosis of left eye is seen 

4,6- normal

5- muscles of mastication+sensations of face: normal

7- no deviation of mouth
Ability of closure of right upper eye lid is decreased Unable to raise eyebrows
Unable to close her eyes completely.

8- normal 

9,11,12-normal

10 - difficulty in swallowing 

• Motor tone -normal

• Power- upper limb            lower limbs 

Right.         4/5                      4/5

Left            4/5                       4/5



• Reflexes:       Right                Left 
biceps:             2+                       2+
Triceps:            2+                      2+
Supinator:        -                           -
Knee:                 2+                     2+
Ankle:                -                          -
Plantar: withdrawal flexion

Sensory examination:

• Spinothalamic tract: Right          left

     Crude touch            intact            intact    

     Pain                        intact              intact 

     Temperature           intact           intact 

• Posterior column:     

      Fine touch          intact               intact            

     Vibration.            intact              intact 

           
• Cortical:

     Graphesthesia      +              +

     Stereognosis        +                +

     tactile sensation   +             +

• Cerebellar signs:
       • Ataxic gait 
       •Finger nose test - positive with left hand 
       •Past pointing



-> Investigations:
CBP:Haemoglobin 11.5 gm/dlTLC:6500cells/cu mmPlatelet:2.36 lakhs/cumm 



RFT :S. Creat: 1.1mg/dlBlood urea: 27mg/dlNa: 143 Cl:98K:3.6 

LFT:Total Bilirubin:0.77Direct Bilirubin:0.23ALP: 244AST:22Albumin: 3.7


Rbs:424 mg/dl 
Hba1c: 7.4g%Urine for ketone bodies - negative Uric acid -2.7 CUE: ALBUMIN +SUGARS  +++


-> Provisional Diagnosis 
Acute cerebrovascular accident with chronic lacunar infarct. 

-> Treatment: 
1. Tab. ECOSPIRIN 75 mg  po/hs 9 pm 
2.Tab .Glimiperide 2 mg PO/OD 
3.Tab.Metformin 1000 mg PO/OD
4.Tab.Thyronorm 100mcg PO/OD

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