33 year old female with weakness of left upper limb

This is an 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.



A 33 years old female came to the GM OPD with chief complaints of 

 - Deviation of mouth to right side

 - Weakness of Left Upper Limb on 31/12/2021 at 8:14 am.

History of present illness: 


She was apparently asymptomatic 4 days ago. Then as she was coming out of her washroom she was unable to use her left upper limb followed by which she developed deviation of mouth to the right side. It was associated with drooling of saliva from the right angle of mouth. She also developed parasthesia over face and left upper limb.Her  symptoms are improving gradually. She was initially aphasic but now she is able to speak. She also c/o fine tremors in right hand fingers since morning (on 31/12/21).

She was admitted in KIMS, Narketpally 1 month back for Acute GE with polyarthralgia with hypoproliferative marrow.

- No c/o headache.

- No c/o nausea.

- No c/o fever.

- No c/o vomitings.

Link to the blog when she was admitted for the first time is given as follows-

https://medcases1.blogspot.com/2021/12/a-case-of-30-year-old-female.html

Past history: She is a k/c/o SLE on medication since 2 months.

No history of DM, HTN, TB, BA, Epilepsy, CAD.

Family h/o: K/C/O DM and HTN In mother.

Personal h/o: 

Diet -mixed 

Appetite - decreased since 2 months 

Bowel habits - regular 

Bladder habits - regular

Sleep - adequate 

No addictions 

Obstetric history :

Age of marriage - 18

P2L2 

General examination:

 Patient is conscious, coherent,cooperative ,thin built and poorly nourished. 

Deviation of mouth to right side.


Nasolabial fold on left side absent

Mild pallor present.


No icterus, cyanosis, clubbing, lymphadenopathy, Edema.


Vitals: 

Pulse rate - 80 bpm 

Temperature- 98.2 degree Fahrenheit 

RR - 15 cpm 

BP - 100/80 mmHg 


Systemic examination : 

CVS : S1 S2 + , no added murmurs 

RS :BAE + ,NVBS heard 

P/A :soft , non tender 

        No organomegaly 

        No distension 

        Bowel sounds heard


CNS:

GCS- E4V5M6

EOM- Full

Pupils- B/L dilated, reacting to light 

Higher mental functions intact.

Sensory examination was normal 

MOTOR SYSTEM:

Tone-.                Rt.                            Lt.

          UL             N                              N

          LL.            N                               N

Power-

          UL       5/5                           4/5

          LL         5/5                          5/5

Reflexes-

          B-    +                                +

          T -    +                                 +

          S-     +                                 +

          K-      +                                +

          A-     +                                +

          P-    Flexor                     Flexor


Hand grip 100%                       30%

INVESTIGATIONS




Provisional diagnosis-

CVA WITH LEFT UPPER LIMB MONOPARESIS WITH ACUTE INFARCT IN THE RIGHT PARIETAL LOBE.

SECONDARY TO SLE VASCULITIS.

WITH K/C/O SLE

With K/C/O RUPTURED SEBACEOUS CYST.

Treatment 


1. TAB. ECOSPIRIN 150 mg PO/OD/HS

2. TAB. CLOPIDOGREL 75 mg PO/OD

3. TAB. ATORVASTATIN 40 mg PO/OD/HS

4. INJ. DEXAMETHASONE 8 mg I.V./OD

5. INJ. PANTOP 40 mg IV/OD

6. TAB. HCQ 200 m PO/OD

7. BP/PR/TEMPERATURE MONITORING HOURLY

8. GRBS MONITORING 6th hourly

9. PHYSIOTHERAPY OF LEFT UPPER LIMB

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