72 F, C/O deviation of mouth to the left side and slurring of speech
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MED CASE :
72 year old female with deviation of mouth to left side and slurring of speech.
CHIEF COMPLAINTS:
Patient came to general medicine OPD
With complaints of deviation of mouth to left side and slurring of speech.
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 1 week ago and she developed swelling, redness and tenderness over left lower limb after scratching her leg for which has been undergoing regular dressing.
Few hours before admission, Patient was doing her daily activities in the morning and she suddenly developed giddiness and had a fall at home.
She was noticed by the attenders few hours later and she was gaining consciousness slowly. They observed that her mouth was deviated to the left side and had slurring of speech. Her symptoms were also associated with weakness of left upper limb which was sudden in onset and non- progressive in nature.
Her condition was not associated with any involuntary movements.
PERSONAL HISTORY:
Appetite is normal. She eats breakfast and drinks 'java' on time and has fruits as well.
She eats lunch and takes an afternoon nap and has snacks and tea in the evening. She has a habit of eating chapathi for dinner with curries.
Her Sleep is adequate.
Her bowel and bladder activity is regular.
She is a housewife. Her attenders mentioned that she has a habit of taking painkillers for joint pains or body pains.
PAST HISTORY:
Known case of Hypertension and diabetes since 16 years. She takes tab. Glycomet for diabetes and amlodipine 5 mg for hypertension regularly.
Not a known case of CVA, CAD, TB, Asthma, thyroid disorders.
No history of previous surgeries in the past.
ALLERGIC HISTORY:
No allergic history to any kind of food or drugs.
GENERAL EXAMINATION:
THE PATIENT IS CONSCIOUS, COHERENT AND CO COOPERATIVE
PALLOR is present
No ICTERUS
No CLUBBING
No CYANOSIS
No LYMPHADENOPATHY
No EDEMA
TEMPERATURE: Afebrile
PR:80bpm
BP:110/80mmhg
RR:16cpm
GRBS: 155 mg/dl
SYSTEMIC EXAMINATION:
CVS: S1 S2 Heard. No murmurs heard.
RS: BAE +. Normal vesicular breath sounds heard. No added sounds.
ABDOMEN EXAMINATION:
Inspection:
Abdomen is flat.
No sinuses,scars, pulsations, peristalsis.
Umbilicus is central and inverted.
All quadrants of Abdomen move equally with respiration.
Palpation:
Abdomen is soft on palpation and no tenderness noted in any quadrants.
Percussion:
Resonant note is heard on percussion
shifting dullness negative
Auscultation:
Bowel sounds are heard.
CNS:
Tone: UL rt- N lt-N
LL rt- N lt-N
Power: UL rt- 3/5 lt- 4/5
LL rt- 3/5 lt- 4/5
Reflexes:
Biceps rt - lt -
Triceps rt - lt -
Supinator rt - lt -
Knee rt- lt -
Ankle rt - lt -
INVESTIGATIONS:
23/8:
FBS: 129 mg/dl
PLBS: 172 mg/dl
Hemogram:
Hb: 9.3
TLC: 15900
PCV: 26.1
MCV: 81.1
MCH: 28.9
RBC COUNT: 3.22
PLT COUNT: 5.1
RFT:
Urea: 18
Creat: 0.9
Na: 130
K: 3.0
Cl: 98
26/8:
Hemogram:
Hb: 10.3
TLC: 8900
PCV: 30.1
MCV: 83.6
MCH: 28.6
RBC COUNT: 3.60
PLT COUNT: 6.59
RFT:
Urea: 20
Creat: 0.9
Na: 136
K: 3.4
Cl: 98
28/8:
Hemogram:
Hb: 9.2
TLC: 9600
PCV: 27.3
MCV: 85
MCH: 28.6
RBC COUNT: 3.21
PLT COUNT: 4.99
RFT:
Urea: 16
Creat: 0.7
Na: 134
K: 3.3
Cl: 98
DIAGNOSIS:
CVA ISCHEMIC STROKE SECONDARY TO ACUTE INFARCT IN LEFT MCA TERRITORY
RIGHT MOTOR FACIAL NERVE PALSY.
COURSE IN THE HOSPITAL:
The patient came to General medicine OP with a complaint of deviation of mouth to left side and slurring of speech.
The patient was admitted in general medicine ward and all the necessary investigations were done. Her Blood pressure and GRBS was normal at the time of admission.
Patient had difficulty feeding due to the deviation of mouth to left side. She was placed on liquid diet.
The patient had left lower limb cellulitis which was treated with Magnesium sulphate crystals and glycerine combined with regular dressing. Then she was taken for chest X-ray to rule out any respiratory diseases.
The laboratory reports have shown that the patient has pre-renal Acute kidney injury and its necessary treatment was initiated immediately. Her Hemogram report has shown that she has mild Anemia which was treated conservatively.
MRI of brain (plain) was done to find out the abnormal pathology that caused the above neurological deficits.
IMPRESSION :
- ACUTE INFARCT ON LEFT CORONA RADIATA AND CENTRUM SEMIOVALE - S/O LEFT MCA TERRITORY INFARCT.
- MILD DIFFUSE CEREBRAL ATROPHY.
- BILATERAL PERIVENTRICULAR SMALL VESSEL ISCHEMIC CHANGES.
- FOCAL AREA OF ENCEPHALOMALACIA WITH SURROUNDING GLIOSIS NOTED IN RIGHT CORONA RADIATA AND CENTRUM SEMIOVALE - SEQUALAE OF OLD VASCULAR INSULT.
The patient was given symptomatic treatment for the 3 days of admission. Patient is shifted to soft diet eventually.
Her bowel and bladder activity is normal.
Regular dressing to the left lower limb was done with MGSO4 + Glycerin, by the general surgery department and the cellulitis has eventually resolved.
The treatment for pre-renal Acute kidney injury was also given and it started resolving too. Her hemoglobin level has slowly imporved too.
Patient is hemodynamically stable and advised for discharge. Although the neurological deficits due to stroke would be permanent.
PROBLEM THAT LEAD TO THE PRESENTING ILLNESS:
The patient was a know diabetic and hypertensive for 16 years. She is at risk of CVA ischemic stroke because of her underlying comorbidities.
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