The patient was apparently asymptomatic 2 hrs back. Then she suddenly fell down from chair on to right side followed by which patient attenders noticed and got her up during which they noticed weakness of right upper limb and right lower limb. Slurring of speech with deviation of mouth to left side is present. This event was not preceded by dizziness palpitations or any syncopal attack.There is no history of involuntary movements, loss of consiousness, tongue bite, chest pain, SOB, orthopnea, PND, vomitings, loose stools, fever.
Past history:
No h/o similar complaints in past
Not a known case of DM/HTN/EPILEPSY/CVA/CAD
Personal history:
Mixed diet with normal appetite and normal bowel/bladder movements
No h/o alcohol intake
No h/o smoking
No significant family history.
General examination:
Moderately built; poorly nourished.
Afebrile
Pallor present
Icterus negative
No cyanosis, clubbing, lymphadenopathy, Edema.
No short neck
No scars; no h/o trophic ulcers
No neurocutaneous markers
Bp 160/80 mm Hg
Pr 80 bpm
Rr 26cpm
SpO2 99% at RA
Grbs 118mg%
E4V3M6
CVS: s1 s2 heard, no murmurs
RS: bae + nvbs heard
PA: soft ,non-tender
CNS:
HMF- patient is conscious
Oriented to place/time/person
No h/o aphsia
No h/o dysphonia
No h/o memory loss
No h/o emotional lability
Cranial nerves-
CN 7- left side deviation of mouth
Able to blow cheeks
Loss of right side nasolabial fold
Frowning present
CN 1,2,3,4,5,6 8, 9, 10, 11,12- intact
MOTOR SYSTEM:
Right. Left
Bulk: inspection Normal. Normal
palpation. Normal. . Normal
Measurements:
U/L 23cm. 23cm
L/L 35cm 35cm
Tone:
UL. Normal. Normal
LL. Normal. Normal
Power:
Upper limb:
Shoulder:
Flexion: 3/5. 4/5
Extension: 3/5. 4/5
Lateral rotation: 3/5. 4/5
Medial rotation: 3/5. 4/5
Abduction: 3/5. 4/5
Adduction: 3/5. 4/5
Elbow:
Flexion(biceps): 3/5. 4/5
Extension(triceps): 3/5. 4/5
Lower limb:
Iliopsoas 3/5. 4/5
Adductor femoris 3/5. 4/5
Gluteus medius 3/5. 4/5
Gluteus maximus 3/5. 4/5
Hamstrings 3/5. 4/5
Quadriceps femoris 3/5. 4/5
Tibialis anterior. 3/5. 4/5
Tibialis posterior. 3/5. 4/5
Peroneii. 3/5. 4/5
Gastronemius. 3/5. 4/5
Extensor Digitorum longus. 3/5. 3/5
Flexor digitorum longus 3/5. 3/5
Reflexes:
Superficial reflexes:
Right. Left
Corneal. P P
Conjunctival P. P
Abdominal + +
Plantar Extensor. mute
Deep tendon reflexes:
Right. Left
Biceps. +++ +
Triceps. +++ +
Supinator. +++ +
Knee +++ +
Ankle. + +
Plantar. Extensor. Mute
SENSORY SYSTEM:
RIGHT. LEFT
SPINOTHALAMIC:
Crude touch. N. N
Pain. N. N
Temperature N. N
POSTERIOR:
Fine touch. N. N
Vibration. N. N
Position sensor. N. N
CORTICAL:
2 point discrimination N. N
Tactile localisation. N. N
CEREBELLUM:
Titubation - absent
Ataxia - absent
Hypotonia- absent
INVESTIGATIONS:
HEMOGRAM :
Hb 10.9gm/dl
Platelets 1.8lakhs/cumm
TLC 4000cells/cumm
Lymphocytes 20%
Smear- normocytic normochromic anemia
BLOOD-RANDOM SUGAR:
RBS 105mg/dl
RFT:
Urea 36mg/dl
Creatinine 0.8mg/dl
Uric acid 6mg/dl
Calcium 10mg/dl
Phosphorus 3.4mg/dl
Sodium 141mEq/l
Potassium 3.6mEq/l
Chloride 99mEq/l
SERUM ELECTROLYTES:
Na+ 138mEq/l
K+ 3.6 mEq/l
Cl- 95mEq/l
MRI:
Acute infarct in left lentiform nucleus- MCA artery.
No evidence of hemorrhage.
DIAGNOSIS:
CVA- Right sides hemiparesis with acute infarct in Left lentiform nucleus with umn type left side fascial nerve palsy
Course in hospital stay : patient subjectively felt better on subsequent days with improvement of power from 3/5 to 4-/5 on right side .
TREATMENT:
1) Inj. Opitneuron 1amp in 500ml NS/IV/OD
2) Tab. Pan 40mg OD
3) Tab. Aspirin 150mg OD
4) Tab. Clopitab 75mg OD
5)Tab. Atorvastat 20mg /H/S
6) Physiotherapy of upper and lower limbs.
7) monitor BP, PR, Temp.
ADVICE AT DISCHARGE:
Tab Aspirin 75 mg /od
Tab clopitab 75mg/od for 15 days
Tab atorvas 20 mg H/S
Tab MVT od
Physiotherapy of right upper and lower limb
Home Bp monitoring .
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