33 year old female patient with weakness in the left upper limb

Medicine E log

“This is an online e log book to discuss our patient’s de- identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”

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 since three days.

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.

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

Not a k/c/o DM, HTN, TB, BA, Epilepsy, CAD.

Family history: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

G2P2L2 

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 

Tone- Right. Left.

          UL N N

          LL N N

Power-

          UL 5/5 4/5

          LL 5/5 5/5

Reflexes-

          Biceps- + +

          Triceps- + +

          Supinator- + +

          Knee- + +

          Ankle- + +

Hand grip 100% 30%

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.

Investigations:

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