case of 50 year old female patient
This is S.samhitha reddy . A dental 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
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
PP0
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