A 72 year old woman with sudden inability to speak meaningfully since three days
November 26, 2020
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardians signed informed consent.
Here we discuss our individual patient's problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with current best evidence based inputs.
This E-log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
Her is the case as I have seen:
Case Discussion
72 year old female came with complaints of
-irrelevant talk since 4 days
History of Present Illness
-Pt was apparently alright till 4 days back when, while she was doing her routine works, suddenly developed irrelevant talk(not oriented to time, place, person)
-No H/o loss of consciousness or trauma
-No H/o fever,headache, blurring of vision, tinitus
Past History
-Pt is k/c/o hypothyroidism since 2 years which she is being treated with Tab Thyronorm 25mg since 2 years
-15 years back Pt complained of sleeplessness when she visited a Psychiatrist, where she was advised to take the following medications:
- Mitrazipine
- Amitryptaline + Pregabalin
- Etizolam + propranolol
- Levosulpride
-20 years back the patient complained of generalized weakness when she was advised by a neurologist.
-Not a k/c/o Diabetes, hypertension,TB, Epilepsy
Personal History
-Patient is a non-vegetarian with normal appetite and having adequate sleep and normal bowel and bladder habits and no addictions.
On Examination
-Pt is conscious and coherent
-Pt is moderately built and moderately nourished
-Pallor-Negative
-Icterus- Negative
-Cyanosis- Negative
-Clubbing- Negative
-Lymphadenopathy- Negative
-Edema- Negative
Vitals
BP: 150/80 mmHg
PR: 82/min
RR: 20 cycles/min
Temp: 98.4
SPO2: 98%
GRBS: 108mg%
CVS: S1 S2 heard no murmurs
RS: BLAE + , NVBS
ABD: Soft, Non tender
CNS:
-Patient is conscious and not oriented to Time, place, person
-Speech is incoherent and slurred
-Fluency is present
-Comprehension (?)
-Repetition Absent
-Sense of smell : (+)
-Visual Acuity: (+)
-EOM Movements: (+)
-Pupil Size: Normal and Dilated
-Direct Light Reflex/Corneal Light Reflex: (+)
-Ptosis: (-)
-Nystagmus: (-)
Motor System Examination
Tone
Upper Limb Lower Limb
Right Normal Normal
Left Normal Normal
Power
Right 4-/5 4-/5
Left 4+/5 4+/5
Superficial Reflexes
Right Left
Corneal. + +
Conjunctival + +
Pharyngeal + +
Palatel + +
Abdominal + +
Plantar + +
Deep Tendon Reflexes
Right Left
Biceps ++ ++
Triceps + +
Supinator + +
Knee ++ ++
Ankle - -
Plantar Mute Mute
Cerebellar Examination
-Finger Nose Test: (+)
-Finger Nose Finger Test: (+)
-Dysdiadokinesia: (+)
-Heel Knee Test: (+)
-Tendon Walking: (+)
Sensory System Examination
Spinothalmic
Right Left
Crude Touch (+) (+)
Pain (+) (+)
Temperature (+) (+)
Posterior Column
Right Left
Fine Touch (-) (-)
Vibration (-) (-)
Position Sense (-) (-)
Cortical
Right Left
Two point Disorientation (-) (-)
Tactile Localization (-) (-)
Grapherthesia (-) (-)
Stereognosis (-) (-)
Gait
Spine Examination
-no spinal tenderness present
-kyphoscoliosis is present
Investigations
Diagnosis
CVA Wernike’s Aphasia with Acute infarction in left Fronto-Parietal, Lentiform nucleus, corona radiata, temporal lobe, and occipital lobe.
TREATMENT
- Tab Ecosporin-AV (75/20mg) OD
- Tab Clopidogrel 75mg OD
- Inj Pan 40 mg IV OD
- Inj Optineuron 1 amp in 100ml NS IV OD
- GRBS monitoring 6th hourly
- BP monitoring 4th hourly
Day 2
Complaints of right leg pain
No Fever spikes
Stools not passed since 3 days
GRBS: 109mg/dL
Pt is conscious and coherent
BP: 110/70mmHg
PR: 72 bpm regular
CVS: S1S2 heard, No murmurs
RS: BLAE+ , NVBS
ABD: Soft and non tender
CNS:
-Patient is conscious and oriented to Time, place, person
-Speech is incoherent and slurred
-Fluency is present
-Comprehension Present
-Repetition Absent
Tone
Upper Limb Lower Limb
Right Normal Normal
Left Normal Normal
Power
Right 4-/5 4-/5
Left 4+/5 4+/5
Deep Tendon Reflexes
Right Left
Biceps ++ ++
Triceps + +
Supinator + +
Knee ++ ++
Ankle - -
Plantar Mute Mute
Sensory System Examination
Spinothalmic
Right Left
Crude Touch (+) (+)
Pain (+) (+)
Temperature (+) (+)
Posterior Column
Right Left
Fine Touch (-) (-)
Vibration (-) (-)
Position Sense (-) (-)
Cortical
Right Left
Two point Disorientation (-) (-)
Tactile Localization (-) (-)
Grapherthesia (-) (-)
Stereognosis (-) (-)
Diagnosis
CVA Wernike’s Aphasia with Acute infarction in left Fronto-Parietal, Lentiform nucleus, corona radiata, temporal lobe, and occipital lobe.
Treatment
- Tab Ecosporin-AV (75/20mg) OD
- Tab Clopidogrel 75mg OD
- Inj Pan 40 mg IV OD
- Inj Optineuron 1 amp in 100ml NS IV OD
- GRBS monitoring 6th hourly
- BP monitoring 4th hourly
- Syrup Cremaffin 10mL/ PO
Day 3
Pt complained of pain in left hypochondrium and left lumbar region
No fever spikes
Stools passed
GRBS: 117mg/dL
Pt is conscious and coherent
BP: 130/90mmHg
PR: 80 bpm regular
CVS: S1S2 heard, No murmurs
RS: BLAE+ , NVBS
ABD: Soft and non tender
CNS:
-Patient is conscious and oriented to Time, place, person
-Speech is incoherent and slurred
-Fluency is present
-Comprehension Present
-Repetition Absent
Tone
Upper Limb Lower Limb
Right Normal Normal
Left Normal Normal
Power
Right 4-/5 4-/5
Left 4+/5 4+/5
Deep Tendon Reflexes
Right Left
Biceps ++ ++
Triceps + +
Supinator + +
Knee ++ ++
Ankle - -
Plantar Mute Mute
Sensory System Examination
Spinothalmic
Right Left
Crude Touch (+) (+)
Pain (+) (+)
Temperature (+) (+)
Posterior Column
Right Left
Fine Touch (-) (-)
Vibration (-) (-)
Position Sense (-) (-)
Cortical
Right Left
Two point Disorientation (-) (-)
Tactile Localization (-) (-)
Grapherthesia (-) (-)
Stereognosis (-) (-)
Diagnosis
CVA(Acute infarction in left Fronto-Parietal, Lentiform nucleus, corona radiata, temporal lobe, and occipital lobe)
Treatment
- Tab Ecosporin-AV (75/20mg) OD
- Tab Clopidogrel 75mg OD
- Inj Pan 40 mg IV OD
- Inj Optineuron 1 amp in 100ml NS IV OD
- GRBS monitoring 6th hourly
- BP monitoring 4th hourly
- Syrup Cremaffin 10mL/ PO
Comments
Post a Comment