case of 37year old female with hemiplegia

This is an a 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.

CASE:

A 37year old women, housewife who is a resident of Kolkata came with the chief complaints of pain in the back of the neck and lower back since 1year and chest pain 4 weeks back.

HOPI:

At the age of 15 She had thypoid

2013 To 2015:

She worked as a weaver once while returning home from the work in the evening she claimed to have seen someone sitting under the trees in the dark she was scared and got fever which was resolved with medication 6 to 7 days later she complained of uneasiness ,while she is combing her hair her husband noticed facial drooping more noticeable when she smiled. She could not walk.suscpecting it to be stroke and took her to the local quack who gave ger injection, on returning home she couldn't even stand and her hands felt numb and weak and her condition detoriated.

The next day she got admitted in the hospital and she was in the hospital for 7 days,she was detected with hypertension and she was shown some physiotherapy techniques and prescribed medication following which she was alright for next 6 months

6 months later there was an occasion in her house, she ate previous days cooked meals and she started complaining of left side chest pain squeezing type , sweating, sob, the pain lasted from 9am to 3 pm ,she was taken to a doctor who did an ECG and detected heartattack, recommended  hospital stay for 6 days, chest pain would occur 1 -2 timesin 2 to 3 months and would last for 1-2 mints

In2020:

One day around 7am while sitting in chairshe started complaining of flashes of light revolving in the dark, her body became stiff and felt confused, slurred speech, her legs and hands felt weak and numb and started drooling and she was rushed to a hospital one day later she started bleeding from nose and mouth.docter reported she again had brain stroke,her symptoms recovered and she still complained of blurred vision so she was refferd to another hospital which reported that her eyes are fine, vision later returned normal and she returned home

In 2022:

She was stressed on 28/7/22 at 12 am and she complained of chest pain which was not relieved by medication , she started sweating profusely and the pain lasted for whole day and next day she was taken to hospital and diagnosed to have heart attack and stayed in ICU for 5 days reffered to higher centre kims on 11/8/22

Daily routine: 

She wakes up at 6 am and cooks for herself and her family and do her household chores and has breakfast at 9am and lunch at 1pm and dinner at 9pm then sleeps by 10pm

PAST HISTORY:

history of hypertension since 9 years

 known case of diabetes since 2020 on medication using glemiperide , 

Pt. c/o chest pain and had 3 incidents of CVA.no epilepsy tb, seizures

FAMILY HISTORY:

Father: was a TB pt.

Mother: had a stroke. Died after a few days

Elder brother: died due to a stroke

Elder sister: became paralyzed after stroke and died a few days later.

Younger sister: had a stroke causing facial palsy. Cannot walk or talk. Rt. had also paralyzed.

PERSONAL HISTORY:

Diet-mixed 

Appetite-normal 

Sleep-adequate

Bowel and bladder movements-regular Addictons-none 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. moderately built and nourished.

Pallor-absent 

Icterus-absent

Clubbing-absent 

Cyanosis-absent 

Generalised lymphadenopathy-absent 

Pedal edema-absent 

Vitals:

Temperature- 98.5degree F

Pulse rate- 79bpm

Respiratory rate- 22cpm

Blood pressure - 130/90mm of hg

Spo2- 98%at room air

Grbs- 200mg /dl

SYSTEMIC EXAMINATION:

Cardiovascular system:

S1 and S2 heard no murmurs heard 

Central nervous system: 

No focal neurological deficit, cranial nerve

 intactCentral nervous system:

Patient is concious coherent.

Higher mental status-

Cranial nerves- intact

Motor 

   Tone- normal 

   Power- normal

 

Cerebellar functions-normal 

Gait- walked with difficulty couldn't hold the chappal

 https://youtube.com/shorts/qYXzsClg2OY?feature=share

Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard

Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable. 

REPORTS:

2d echo cardiograph:

Provisional diagnosis:

Post stroke and post MI secondary to hyperlipidemia and Hypertension 

TREATMENT: