60Y /F WITH RIGHT UPPER AND LOWER LIMB WEAKNESS WITH DEVIATION OF MOUTH TO LEFT

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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 coming up with diagnosis and treatment plans. 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 patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.

20/9/23

This is a case of 60y old female brought to casualty with c/o loss of consciousness since 1 hour,right lower and upper limb weakness since today afternoon ,deviation of mouth towards left side .

Hopi:

Patient was apparently asymptomatic till today when patient attender came to home patient is in unconscious state ,with right lower and upper limb weakness, with deviation of  mouth towards left .

No h/o head ache ,fever ,vomitings

N/k/c/o DM,HTN,CAD,TB ,EPILEPSY

Past history:

patient had similar episode 5 years back and was treated here advised for referring to higher centre but  due to financial status they went to local hospital and given medication and she recovered then 

K/C/O hypertension since 30 years

N/k/c/o DM,CAD,TB ,EPILEPSY

PERSONAL HISTORY:-

Diet - mixed 

Appetite- normal

Sleep - adequate 

Bowel and bladder -regular

Addictions- not present

Allergic history:- No history of any kind of allergies for food/drugs

Family history:- no significant family history 

GENERAL EXAMINATION:- 

Patient is drowsy ,in coherent 

NO PALLOR ,ICTERUS; CLUBBING; CYANOSIS; ; LYMPHADENOPATHY ; EDEMA

Systemic examination:

Cvs-s1,s2 heard

Rs -Bae present

P/a -soft,nt

CNS examination:

Patient is drowsy ,incoherent,but arousable

Bp-160/90 mmHg

Pr-88 bpm

Rr-22 cpm

GCS -E3V2M5

Pupils-both mildly reacting to light

Power: right.     left

     U/l.  0/5.       3/5

      L/l.   0/5.       3/5

Tone.:    right.          .   Left

    U/l.      Increased      normal

    L/l.      Increased.      Normal

Reflexes:   right             left

      B.          +++.             +++

      T.           ++.                ++

      S.           +.                   +

      K.            +++.             +++

      A.            ++.               ++

      P             increased.    Increased

Hemiplegic gait

INVESTIGATIONS:

MRI brain:

Diagnosis:

ACUTE HEMORRHAGIC STROKE ?

WITH K/C/O HTN SINCE 30 YEARS