70 YEAR OLD MALE WITH SLURRING OF SPEECH AND DEVIATION OF MOUTH

Kausalya Varma, Intern 

This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.

 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 diagnosis and treatment plan.  



70 year old male presented with the c/o of slurring of speech and deviation of mouth to the right side since yesterday morning.


HOPI

70 year old male presented with the c/o of slurring of speech and deviation of mouth to the right side since yesterday morning.

- Patient was apparently asymptomatic 10 years back after which he had a history of a thorn prick to the left middle finger which formed a swelling filled with pus.

- Patient was diagnosed to have diabetes mellitus, after which his left middle  finger was amputated. Since then, the patient is on regular diabetic medication. 

- H/O of burning sensation and tingling in both lower limbs since 1 year 

- Patient is having slurring of speech and deviation of mouth to the right side since yesterday morning 

- No H/O weakness of limbs, seizures, trauma, headache/nausea, or fever.

- K/C/O DM type 2 since the last 10 years (on regular medication, Glimi M1) 



EXAMINATION 


Pt is C/C/C

BP:130/80mm hg

PR:96bpm

RR:20/min

GRBS- 261

Temp : Afebrile 








CVS:S1S2 +,No murmurs 

RS :Bilateral air entry present 

       Normal vesicular breath sounds heard 

PA- soft, non tender, bowel sounds heard 


CNS-


Pupils- left- Reacting to light 

             right- dilated, not reacting to light 

Higher mental functions

- Conscious

- Oriented to  time,place and person

- Memory - Intact

- Speech - slurred 


Cranial nerve examination 


          • 1 - olfactory sense - normal


          • 2- visual acuity present


          • 3,4,6 - no ptosis Or nystagmus


          • 5- corneal reflex present 


           • 7- deviation of mouth to right side, loss of nasolabial folds on left side


          • 8- Normal hearing


          • 9,10- position of uvula is central ,Gag reflex- present


          • 11- sternocleidomastoid contraction present


          • 12- no deviation of tongue


Motor system 


Reflexes 

                          Right            Left            

Biceps                -                      -   

Triceps                -                     -    

Supinator            -                     -

 Knee.                  1+.                 1+

Ankle.                  -                     -

Plantars-       Flexion          Flexion 

Power.           Lt.        Rt

Upper limb -4/5.       4/5


Lower limb  -4/5       4/5                                  

               


TONE.                    Lt.        Rt

 Upper limbs           N        N                

 Lower limbs           N         N               


No Involuntary movements

 SENSORY SYSTEM


I – SPINOTHALAMIC       R     L

1. Crude touch                 N     N 

2. Pain.                              N.    N

3. Temperature.               N.     N

II – POSTERIOR COLUMN

1. Fine touch.                    N.    N

2. Vibration.                      N.     N

3. Position sense.             N.     N

4. Romberg’s sign  -Equivocal 

III – CORTICAL

1. Two point 

    discrimination.               N.    N

2. Tactile localisation.       N.    N

3. Graphaesthesia.            N.    N

4. Stereognosis.                N.    N

 CEREBELLAR Tests

No Nystagmus

Finger Nose test - normal

Heel Knee test - normal

Dysdiadokokinesia - normal



Provisional diagnosis 

Acute CVA 

Acute infarct in right middle frontal gyrus/operculum with haemorrhagic transformation 



Treatment 

Inj OPTINEURON 1amp in 500ml NS OD

Tab ECOSPORIN 75mg po od

Tab ATORVAS 40mg PO HS 

GRBS monitoring 6th hourly  

Monitor vitals and inform sos 

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