1801006134-LONG CASE
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CASE
This is a case of a 50 year old male, resident of Miryalguda, factory worker by occupation, presented with
CHEIF COMPLAINTS-
Weakness of right upper and lower limbs with and deviation of mouth to the left since 3 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month ago, then he developed giddiness and weakness of left upper and left lower limb which was sudden in onset followed by fall. He was then taken to the hospital where he was treated for the same and diagnosed with hypertension. His symptoms resolved in around 3 days. The patient was compliant with his hypertension medication for 20 days and stopped taking it after that.
The patient then developed weakness of right upper limb and lower limb 3 days ago which was sudden in onset. He noticed the weakness on his right side when he woke up in the morning. He felt unsteady as he stood up after waking up.
The weakness of right side was also associated\ and deviation of the mouth to his left side. He was taken to a hospital nearby where he underwent a CT scan. He was then referred to our hospital the next day.
There is no history of difficulty in swallowing, behavioural abnormalities, fainting, sensory disturbances, fever, neck stiffness, altered sensorium, headache, vomiting, seizures, abnormal movements, falls.
Fracture near the right elbow due to fall from the tree 30 years ago ,so he cannot extending his right hand completly.
He is a known case of hypertension since 1 month .
Not a k/c/o Diabetes,asthma, coronary artery diseases,epilepsy,thyroid disorders.
FAMILY HISTORY:
No similar complaints in the family
PERSONEL HISTORY:
( daily routine )
The patient wakes up at 4:00am in the morning daily. He has tea and goes to work in the ice factory. He lives very close to the ice factory. He comes home and has breakfast at around 8 to 9 am. He usually has rice and curry for breakfast. He then goes back to work and comes home for lunch at around 2:00 pm. He usually has rice with curry and dal for lunch. He consumes chicken or mutton thrice weekly. He sometimes takes a nap in the afternoon depending on his work for the day. He finishes work by around 6:00 pm following which he comes home, has tea and takes a bath. Sometimes he works until 9:00 pm. He sleeps by 9:00 pm.
The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days.
He consumes alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago.
Bowel and bladder movements are regular.
TREATMENT HISTORY:
He is on antihypertensives (amlodipine and atenolol) since 1month but 10 days onwards he stopped medications.
GENERAL EXAMINATION:
Patient is conscious, cooperative, with slurred speech
Well oriented to time, place and person
Moderately built and moderately nourished.
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Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
Vitals :-
Temp - afebrile
BP - 145/80 mm Hg
Pulse rate - 78 bpm
Respiratory rate - 14 cycles per minute
SYSTEMIC EXAMINATION:
CNS EXAMINATION:
Dominance - Right handed
Higher mental functions
• conscious
• oriented to time,person and place
• memory - immediate,recent,remote intact
•slurring of speech
GCS( Glasgow coma scale)
Cranial nerves -
CN1:
Sence of Smell - Normal
2. CN2:
visual acuity - normal
3. 3,4,6 CN
EOM movement - normal
5 CNMotor - masseter, Temporalis, - N, N
Reflexes - Corneal
7 CN
Motor
Occipito frontalis - equal on both sides
Orbicularis oculi - equal onboth side
Deviation of mouth to the left side, upper half of left side and right side normal
8 CN - hearing is normal, no vertigo or nystagmus
9,10CN- no difficulty in swallowing
11CN- neck can move in all directions
12CN - tongue movements normal, no deviation
Power:-
Rt UL - 3/5 Lt UL-5/5
Rt LL - 3/5 Lt LL-5/5
Tone:-
Rt UL - Increased
Lt UL- Normal
Rt LL- Increased
Lt LL- Normal
Reflexes:
Right Left
Biceps: +++ ++
Triceps: +++ ++
Supinator: ++ ++
Knee: +++ ++
Ankle: ++ ++
Plantar: Muted Flexion
Involuntary movements - absent
Fasciculations - absent
Sensory system -
-Pain, temperature, crude touch, pressure sensations normal
-Fine touch, vibration, proprioception normal
-two point discrimination -able to discriminate and tactile localisation -able to localise
Cerebellum -
Finger nose test normal, no dysdiadochokinesia, Rhomberg test could not be done
Autonomous nervous system - normal
CVS EXAMINATION:
JVP: Normal
INSPECTION:
Chest wall symmetrical
Pulsations not seen
PALPATION:
Apical impulse – normal
Pulsations – normal
Thrills absent
PERCUSSION:
No abnormal findings
AUSCULTATION:
S1, S2 heard
No murmurs
No added sounds
ABDOMINAL EXAMINATION :-
INSPECTION:
1. Shape – flat
2. Flanks – free
3. Umbilicus – Position-central, Shape-normal
4. Skin – normal
5. Hernial Orifices - normal
PALPATION:
Abdomen is soft and non tender
No hepatomegaly
No splenomegaly
Kidneys not enlarged, no renal angle tenderness
No other palpable swellings
Hernial orifices normal
PERCUSSION:
Fluid Thrill/Shifting dullness/Puddle’s sign absent
AUSCULTATION:
Bowel sounds – normal
No bruits.
RESPIRATORY EXAMINATION :-
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
PROVISIONAL DIAGNOSIS:
Acute Cerebrovascular accident with Right Hemiparesis due to involvement of internal capsule posterior limb
INVESTIGATIONS
Anti HCV antibodies rapid - non reactive
HIV 1/2 rapid test - non reactive
Blood sugar random - 109 mg/dl
FBS - 114 mg/dl
Hemoglobin- 13.4 gm/dl
WBC-7,800 cells/cu mm
Neutrophils- 70%
Lymphocytes- 21%
Eosinophils- 01%
Monocytes- 8%
Basophils- 0
PCV- 40 vol%
MCV- 89.9 fl
MCH- 30.1 pg
MCHC- 33.5%
RBC count- 4.45 millions/cumm
Platelet counts- 3.01 lakhs/ cu mm
SMEAR:
RBC - normocytic normochromic
WBC - with in normal limits
Platelets - Adequate
Haemoparasites - no
CUE:
Colour - pale yellow
Appearance- clear
Reaction - acidic
Sp.gravity - 1.010
Albumin - trace
Sugar - nil
Bile salts - nil
Bile pigments - nil
Pus cells - 3-4 /HPF
Epithelial cells - 2-3/HPF
RBC s - nil
Crystals - nil
Casts - nil
Amorphous deposits - absent
LFTs:
Total bilirubin - 1.71 mg/dl
Direct bilirubin- 0.48 mg/dl
AST - 15 IU/L
ALT - 14 IU/L
Alkaline phosphatase - 149 IU/L
Total proteins - 6.3 g/dl
Albumin - 3.6 g/dl
A/G ratio - 1.36
Blood urea - 19 mg/dl
Serum creatinine - 1.1 mg/dl
Electrolytes
Sodium - 141 mEq/L
Potassium - 3.7 mEq/L
Chloride - 104 mEq/L
Calcium ionised - 1.02 mmol/L
T3 - 0.75 ng/ml
T4 - 8 mcg/dl
TSH - 2.18 mIU/ml
X-RAY
ECG
MRI scan
CONFIRMED DIAGNOSIS:
Cerebrovascular accident with Right sided hemiparesis ,
Acute infarct in posterior limb of internal capsule.
TREATMENT:
Inj. OPTINEURON in NS 100 ml
Tab. ECOSPRIN
Tab. CLOPITAB
Tab. ATOROVASTAT
Tab. STAMLO BETA
Physiotherapy is advised
17/03/23:
S:
Stools passed
O:
O/e
Patient is c/c/c
BP: 150/90mm hg
Pr: 84bpm
Rr: 18cpm
GRBS:108mg/dl
Cvs: s1 and s2 present. No murmurs
Rs: b/l air entry present. NVBS
P/a soft non tender
CNS:
Tone: R. L
UL increased increased
LL. N. Increased
POWER: R. L
UL 4/5. 5/5
LL. 4/5. 5/5
REFLEXES: R. L
biceps. 3+. 3+
Triceps. 3+. 3+
Supinator. 2+. 3+
Knee. 3+. 3+
Ankle. 2+. 3+
Plantar. Extension flexion
A:
CEREBROVASCULAR ACCIDENT WITH RIGHT HEMIPARESIS WITH ACUTE INFARCT IN POSTERIOR LIMB OF LEFT INTERNAL CAPSULE
K/C/O HTN SINCE 1 MONTH
P:
1. INJ. OPTINEURON 1 AMP IN 100ML NS IV/OD
2. TAB. ECOSPRIN AV 75/10 PO/HS
3. TAB. CLOPITAB 75 MG PO/OD
4. PHYSIOTHERAPY OF RIGHT UPPER AND LOWER LIMB
5. SYRUP. CREMAFFIN PLUS 15ML PO/HS
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