CVA STROKE - 63 year old Female

 Introduction: This is an online E-log Entry Blog to discuss, understand and review the clinical scenarios and data analysis of patients so as to develop my clinical competency in comprehending clinical cases, and providing evidence-based inputs. 

Note: The cases have been shared after taking consent from the patient/guardian. All names and other identifiers have been removed to secure and respect the privacy of the patient and the family.

Here, 

  A 63 year old female, shopkeeper by occupation, now admitted in the ICU, initially presented with chief complaints of diminished vision in left eye since 6 months and was admitted to opthalmology department for cataract surgery.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6 months ago when she developed DOV in her left eye, which was insidious in onset and gradual in progression.

She underwent cataract surgery on 27th October for immature senile cataract in her left eye with PCIOL implantation, following which she had an episode of sudden fall at 4 Am on 31st October 2021, not associated with giddiness.

She suddenly fell off the bed in her sleep and the attender, who was present there noticed later that the patient's mouth was deviated to the left side with slurring of speech and post the episode the patient was unable to lift her right upper and lower limbs and was quite irritable and insisted on leaving the hospital. 

There is no history of trauma to head.

No history of fever 

31/10/2021

She is complaining of bilateral knee pain post the fall which is dull aching and intermittent in nature, aggravated on rest and relieved on oil massage.

She is also complaining of right shoulder pain associated with restriction of overhead abduction movement, not associated with swelling.

There is history of trauma to the right shoulder thrice in the past.

01/11/2021

Bilateral knee pain and right shoulder pain has not subsided yet, patient is on medication.

PAST HISTORY

1. Patient is a known case of Hypertension since 10 years for which she has been taking Telvas 12.5 mg OD.
2. She's also a known case of Diabetes since 5 years for which she's been on Glyciphage SR 500 mg OD.
3. Not a known case of TB, Bronchial Asthma, epilepsy, COPD, Coronary Artery Disease.

PERSONAL HISTORY 

• Her appetite has decreased.
• She takes mixed diet.
• Bowel and Bladder movements are regular.
• Sleep is disturbed.
• No known addictions or allergies.

 

MENSTRUAL HISTORY

Attained menopause.

FAMILY HISTORY

Non contributory

TREATMENT HISTORY

Cataract surgery for right eye, 4 years ago.

PHYSICAL EXAMINATION

 General Examination:

• Patient was examined in a well lit room after taking consent. 
• She was conscious, non coherent and irritable and insisted on going home.
• She was moderately built and moderately nourished.
• No signs of pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema.
• She was afebrile.
• Pulse rate - 74 bpm
• Respiratory rate -  13 breathes per minute 
• Blood pressure - 120/80 mm Hg
• SpO2 - 92%