55 year old female with difficulty in speech
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I've 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 a diagnosis and treatment plan.
Following is the view of my case:
CHIEF COMPLAINTS:
A 55 year old female , daily wage labourer,right handed from kondagadapa came with chief complaints of difficulty in speech
History of presenting illness:-
Patient was apparently asymptomatic 35 years ago then patient husband noticed sudden loss of consciousness followed by stiffening of both limbs which is flexion of upper limbs and lower limbs with fisting of hands not associated with up rolling of eyes, frothing in mouth , urinary and fecal incontinence,episode lasted for 10 mins. It occurred first time during her second pregnancy(35 years ago) ( trimester?) and excluding this her pregnancy was uneventful and it was a narmal vaginal delivery , since then she has frequent seizure episodes , which is once in a month, patient is not compliant with medication, seizure episodes are frequently preceded by emotional distress and reduced intake of food.
H/o fall 8 years ago during a seizure episode sustained an open wound head injury on left side due to a nail (8-10 stitches),and taken to hospital, for which MRI was done , doctors said that she had peanut sized bleed in left cerebral hemispheres and she had incoherent speech after that incident,slowly recovered after 1 month with the use of some unknown medication
H/o similar complaint of incoherent speech after seizure activity 7 years back , lasted for ten days and recovered.
in between the episodes of incoherent speech,she still continues to have seizures once/twice a month
3rd episode
on thursday night she told her husband that she was not feeling well before going to bed , on friday morning at 5:00 am her husband tried to wake her up ,but she didnt respond and was having another episode of seizure, episode lasted for a longtime than usual ,she was staring and had a short period of memory loss and she was unable to recognise her family members , after a while she was able to recognise them but couldn't identify their names and object names and using monosyllables to express what she wants, she is struggling to speak full sentences and able to tell use of an object but not the name .
PAST HISTORY: H/o TB on ATT for 6 months .
Not a known case of Hypertension, diabetes,asthma, thyroid disorders.
Hysterectomy 10 years ago
PERSONAL HISTORY:DIET: Mixed
appetite: decreased
bowel and bladder : regular
sleep adequate
addictions: none
DAILY ROUTINE:
she wakes up at 5:00am and cooks food , cleans the house, by 9 /10 am she takes her first meal (mixed diet) and sometimes goes to paddy field and 9pm she eats dinner and sleeps.
Before the injury ,she went to paddy fields and did heavy work , after injury as her seizure episodes are increasing , she limited her activities .
FAMILY HISTORY:
NO significant family history
TREATMENT HISTORY: on ATT till november , occasionally on unknown medication for seizures .
GENERAL PHYSICAL EXAMINATION:
patient is examined in well lit room,
patient is conscious and cooperative but not coherent not oriented to time and place.
She was moderately built and moderately nourished
VITALS:
BP: 110/70mmHg on right arm
Pulse rate : 92bpm on right side.regualr rhythm, normal volume and character
Peripheral pulses are felt with equal intensities, no radio femoral delay,arterial wall is not thickened.
RR: thoracoabdominal type, 20cpm, depth is normal
Temperature: afebrile
No pallor, icterus, cyanosis,clubbing, generalized lymphadenopathy, pedal edema
No nystagmus,squint,ptosis
No engorged neck veins
No evidence of xanthomas
1.HIGHER MENTAL FUNCTIONS:
Conscious and cooperative
Appearence and behaviour: unhygienic and smiling after responding to each question.
Emotionally stable
Recent,immediate, remote memory intact
Speech: fluency normal, comprehension unaffected, repetition of words present
Calculation cannot be elicited
Right handed individual
2.CRANIAL NERVE EXAMINATION
Olfactory: normal
Optic: normal
visual field: cannot be assessed
Colour vision : cannot be assessed
Pupil: NSRL
3,4,6: normal ocular motility in all directions
Trigeminal: normal sensory ,motor
Facial nerve:
Forehead wrinkling present
Able to close her eyes
Able to blow ( not fully)
Angle of mouth slightly deviated to left
8nerve: normal hearing no nystagmus
9 and 10 nerve:normal
11: scm and trapezius- normal
12: deviation of tongue to right side no fasiculations
IMPRESSION:
Left Umn facial palsy
Left hypoglossal nerve palsy umn type
MOTOR EXAMINATION
Attitude: in supine position,both upper and lower limb extended
Nutrition
U/L R L
Arm -23 cm 24cm
Forearm-6.8inches 7inches
L/L
Thigh: 8.8inch 8.8inch
Calf: 15 inch 15inch
No atrophy noted
Tone:
Right left
Ul:Flexors normal normal
Extensors normal normal
Ll: flexors normal normal
Extensors normal normal
Power:
right left
Shoulder:
flexion : 4/5 5/5
Extension 5/5 5/5
Abduction 5/5 5/5
Adduction 5/5 5/5
Internal rotation 5/5 5/5
External rotation 5/5 5/5
Elbow: both limbs
Flexion:5/5
Extension:5/5
Wrist:5/5
Flexion:5/5
Extension:5/5
Abduction :5/5
adduction:5/5
Hip
Flexion:5/5
Extension5/5
Abduction:4/5
Adduction4/5
Internal rotation:5/5
External rotation5/5
Knee
Flexion :5/5 5/5
Extension5/5 5/5
Ankle
Plantarflexion:5/5
Dorsiflexion:5/5
Toe
Movements:5/5
REFLEXES: right left
Corneal N N
Conjunctival N N
Abdominal: present present
Plantar: flexor flexor
DEEP REFLEXES:
Biceps : 3+ 2+
Triceps : 3+ 2+
Knee : +++ 3+
Ankle: ++ ++
No clonus
https://youtu.be/t2JeYnBiWko
SENSORY FUNCTIONS
SPINOTHALAMIC TRACT
Pain , temperature ,presure- intact in all limbs
Posterior column:
Fine touch, vibration and proprioception are intact
CEREBELLAR FUNCTIONS:
Titubation: absent
Nystagmus: absent
Dysmetria:absent
Dysdiadochokinesia: not able to perform
https://youtube.com/shorts/gFIQwCzxhe4?feature=share
Intention tremor:absent
Impression:no signs of cerebellar dysfunction.
https://youtube.com/shorts/0IuNamfxke4?feature=share
CVS:
inspection:precordium is normal
Palpation: apex beat : at 5th intercoastal space in midclavicular line perceived I left lateral position
No palpable thrills or heaves
Auscultation:s1, s2 heard, no murmurs
Respiratory system:
inspection : normal
Palpation: apex beat : at 5th intercoastal space 2cm away from midclavicular line
No palpable thrills or heaves
Auscultation:s1, s2 heard, no murmurs
Respiratory system:
inspection : normal
Palpation:position of trachea:central
And expansion: normal
PERCussion:
Auscultation: bilateral vesicular breath sounds are heard
PER ABDOMEN :
inspection: normal
Palpation: Soft , non tender
No organomegaly
Percussion:no fluid thrill and shifting dullness
Auscultation:bowel sounds are heard
Clinical diagnosis:- aphasia secondary to stroke.
INVESTIGATIONS:
MRI BRAIN:-
DIAGNOSIS:-
PATHOLOGICAL :
ischemic infarcts due to thrombosis /emboli
Differential diagnosis:- anomic aphasia , conduction aphasia.
As her speech is fluent and echolalia is present diagnosis is more towards anomic aphasia
Treatment
Atorvastatin 20mg
clopidogrel 75mg
Aspirin 150 mg
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