A 50 year old female with slurred speech and weakness of lower limb

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

History of presenting illness:

Patient was apparently asymptomatic 1 day  back then she complained of headache,tingling and numbness of head and 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 which subsided itself.
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 .
K/C/O hypothyroidism since 6 yrs on medication T.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 

Moderately nourished and  built .

No pallor,Icterus, cyanosis, clubbing lymphadenopathy, edema


Vitals:

Afebrile

BP-Right Brachial artery 120/90
Left Brachial Artery 150/100 

PR-80bpm

RR-16cpm

Grbs-469mg/dl



Systemic examination:

Central nervous system:

Oriented to time,place,person

Speech: slurred

Cranial nerves: 

1-intact
2- vision: normal
3-ptosis of left eye 
4,6- normal
5-normal( muscles of mastication+sensations of face)
7- no deviation of mouth,ability of closure of right upper eye lid is decreased.unable to raise eyebrows,can't 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
       



Provisional diagnosis:Acute CVA 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

Opthalmology Referral I/V/O Diabetic Retinopathic Changes .
3 Dot and blot haemorrhages seen in superior quadrant of Left eye suggestive of Mild NPDR changes in left eye .
Advised :
Fundoscopy every 6 months .
Strict Glycemic control .

 Investigations:

CBP:

Haemoglobin 11.5 gm/dl

TLC:6500cells/cu mm

Platelet:2.36 lakhs/cumm 



RFT :

S. Creat: 1.1mg/dl

Blood urea: 27mg/dl

Na: 143 

Cl:98

K:3.6 

LFT:

T. Bilirubin:0.77

D. Bilirubin:0.23

ALP: 244

AST:22

Albumin: 3.7



Rbs:424 mg/dl 

Hba1c: 7.4g%
Urine for ketone bodies - negative 
Uric acid -2.7 
CUE: 
ALBUMIN +
SUGARS  +++



10/07/2023
Ward : Medical ward 
Unit : 6
DOA : 9/7/23


S: 
No Fresh Complaints 


O:
Patient is conscious coherent and cooperative 

No icterus,cyanosis,clubbing,
lymphadenopathy

Bp-160/90mmHg
Pr- 72 bpm
Temperature - Afebrile 
Rr- 16cpm
Spo2- 99% on RA
Grbs- 328mg/dl @8am
 

CVS-S1,S2 heard ,no murmurs
RS- BAE present 
NVBS 
CNS-
Pupils- B/L NSRL
Tone  
           UL.               LL 
R.        Normal       Normal 
L.        Normal        Normal 
 
Tone 
 R.      4/5                4/5 
 L.       4/5               4/5
                   
Deep tendon reflexes:

Biceps:         +2       +2

Triceps:        +2       +2

Supinator:.     -         -

Knee:            +2       +2

Ankle:           -           -

Plantar:    flexor      flexor 

P/A- Soft, NT

A:ACUTE CVA with lacunar infarct .
K/c/o DM2 since 6 yrs 
K/c/o hypothyroidism since 6 yrs 

P:
1.RT FEEDS. 200 ml milk 4 th hourly 
2.T.Metformin 1000 mg RT/OD 
    T.GLIMPERIDE 2 MG RT/OD 
3.T.THYRONORM 100 MCG RT/OD

11/07/2023
Ward : Medical ward 
Unit : 6
DOA : 9/7/23

S: 
No fever spikes 
Speech improved 
No Fresh Complaints 


O:
Patient is conscious coherent and cooperative 

No icterus,cyanosis,clubbing,
lymphadenopathy

Bp-130/90mmHg
Pr- 78 bpm
Temperature - Afebrile 
Rr- 16cpm
Spo2- 99% on RA
Grbs- 218mg/dl @8am
 

CVS-S1,S2 heard ,no murmurs
RS- BAE present 
NVBS 
CNS-
Pupils- B/L NSRL
Tone  
           UL.               LL 
R.        Normal       Normal 
L.        Normal        Normal 
 
Tone 
 R.      4/5                4/5 
 L.       4/5               4/5
                   
Deep tendon reflexes:

Biceps:         +2       +2

Triceps:        +2       +2

Supinator:.     -         -

Knee:            +2       +2

Ankle:           -           -

Plantar:    flexor      flexor 

P/A- Soft, NT

A:ACUTE CVA with lacunar infarct .
K/c/o DM2 since 6 yrs 
K/c/o hypothyroidism since 6 yrs 

P:
1. Allow soft diet
2.Inj Optineuron 1 amp in 500 ml NS /IV/OD
3.T.Metformin 1000 mg RT/OD 
    T.GLIMPERIDE 2 MG RT/OD 
4.T.THYRONORM 100 MCG RT/OD


12/07/2023
Ward : Medical ward 
Unit : 6
DOA : 9/7/23


S: 
No fever spikes 
Speech improved 
Complaints of throat pain while swallowing 


O:
Patient is conscious coherent and cooperative 

No icterus,cyanosis,clubbing,
lymphadenopathy

Bp-160/100mmHg
Pr- 76 bpm
Temperature - Afebrile 
Rr- 16cpm
Spo2- 99% on RA

 
CVS-S1,S2 heard ,no murmurs
RS- BAE present 
NVBS 
CNS-
Pupils- B/L NSRL
Tone  
           UL.               LL 
R.        Normal       Normal 
L.        Normal        Normal 
 
Tone 
 R.      4/5                4/5 
 L.       4/5               4/5
                   
Deep tendon reflexes:

Biceps:         +2       +2

Triceps:        +2       +2

Supinator:.     -         -

Knee:            +2       +2

Ankle:           -           -

Plantar:    flexor      flexor 

P/A- Soft, NT

A:ACUTE CVA with lacunar infarct .
K/c/o DM2 since 6 yrs 
K/c/o hypothyroidism since 6 yrs 

P:
1. Allow soft diet
2.Inj Optineuron 1 amp in 500 ml NS /IV/OD
3.T.Metformin 1000 mg RT/OD 
    T.GLIMPERIDE 2 MG RT/OD 
4.T.THYRONORM 100 MCG RT/OD
5.T.ATORVAS-CV 20/75 mg PO/HS





 

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