case of a 50 year old female patient

Hello! This is Likhita Maddula. A medical student. This is an e log that depicts patient centered learning medicine. This E-Log has been created after taking consent from the patient and their relatives.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.

July 10 2023

Case of a 50 year old female patient

This is a case of a 50 year old female patient resident of came to the hospital with 

chief complaints of

- slurring of speech

- weakness in the left lower limb

-tingling and numbness 

All since 1 day

History of presenting illness

The patient apparently asymptomatic since yesterday evening @4 pm when she developed dizziness, headache followed by tingling and numbness in the left temporo parietal area. After taking her usual Metformin tablet, she had approximately 7 episodes of vomiting which was non projectile, with contents of food she's taken in the afternoon which she mentioned was a usual thing that happened whenever her blood glucose level were high. 

She also developed weakness in her left lower limb which was insidious in onset and found difficulty in walking. 

She also had slurred speech. 

Past history

She's a known case of thyroid  since 6 years

(been on thyronorm 100 mcg) 

Diabetes mellitus since 6 years. 

(Been on metformin tablets) 

She was diagnosed with hypertension yesterday. 

N/k/c/o tb epilepsy 

Personal history

Diet : Mixed 

Appetite : Normal 

Bowel and bladder movements: Normal

Sleep adequate 

Addictions : none

Family history- 

No significant family history

GENERAL EXAMINATION:

Prior consent was taken and patient was examined in a well lit room.

Patient was conscious, slurring of speech was observed and cooperative.

No pallor ,icterus, clubbing ,cyanosis.

No generalised lymphadenopathy and bipedal edema

VITALS:

Temperature- 98.6F

BP-160/90 mmhg

PR- 78 bpm

RR-20cpm

Spo2-98%

No associated pain 

CNS examination:

Sensory system: sensation lost in left parieto temporal region including skin around her left eye

Motor system:

                                        Right                   Left

Tone- UL               Normal                         Normal

            LL               Normal                       Normal

Power-           UL       5/5                               5/5

                      LL            4/5                             4/5

Reflexes- Biceps +2                              +2

                 Triceps +2                             +2

    

                 Supinator

                  Knee    +2                               +2

            

                  Ankle  

Co- ordination

Finger nose test      difficulty is seen

Heel shin test           difficulty is seen

Provisional diagnosis

PCA stroke