A 45 Y OLD MALE CAME TO OPD WITH DEVIATION OF MOUTH AN WEAKNESS IN BOTH LEFT UPPER AND LOWER LIMB

C/O

 Deviation of mouth to right side

 - Weakness of Left Upper Limb .and left lower limb

History of present illness: 

He  was apparently asymptomatic yesterday. Then as he was coming out of  room he was unable to use left upper limb followed by which she developed deviation of mouth to the right side. It was associated with drooling of saliva from the right angle of mouth.. He was having sulring of speech .

- No c/o headache.

- No c/o nausea.

- No c/o fever.

- No c/o vomitings.

Past history:no similar complaints in the past

No history of DM, HTN, TB, BA, Epilepsy, CAD.

Personal h/o: 

Diet -mixed 

Appetite - decreased

Bowel habits - regular 

Bladder habits - regular

Sleep - adequate 

addictions      He is an chronic alcholic for 30 yr and he used to drink 1 half a day 

                       BD 1 pack /day since 35 yr 

General examination:

 Patient is conscious, coherent,cooperative





 





REFLEXES EXAMINATION:

https://youtube.com/shorts/NhtYElhOfM8?feature=share


https://youtu.be/Av6GBml37s0


https://youtu.be/AO7nDk1G_nM


https://youtube.com/shorts/ETDOF9RAWac?feature=share


https://youtube.com/shorts/AuWl5ETzmig?feature=share


https://youtube.com/shorts/YsGuGZOdQ4o?feature=share


https://youtube.com/shorts/9G-kr8yS9jw
 


Deviation of mouth to right side.

Nasolabial fold on left side absent

No palor , icterus, cyanosis, clubbing, lymphadenopathy, Edema.

Vitals: 

Pulse rate - 80 bpm 

Temperature- 98.2 degree Fahrenheit 

RR - 15 cpm 

BP - 100/80 mmHg 

Systemic examination : 

CVS : S1 S2 + , no added murmurs 

RS :BAE + ,NVBS heard 

P/A :soft , non tender 

        No organomegaly 

       No distension 

        Bowel sounds heard

CNS:

GCS- E4V5M6

EOM- Full

Pupils- B/L dilated, reacting to light 

Higher mental functions intact.

Sensory examination was normal 

MOTOR SYSTEM:

Tone-. Rt.                                  Lt.

          UL N                               N

          LL. N                              N

Power-

          UL 5/5                            1/5

          LL 5/5                            1/5

Reflexes-

                 R.                            L

          B-   ++                            ++

          T -  ++                            +

          S-   +                          absent

          K-  ++                           +

          A-  +                             +

          P- Flexor                      Flexor

Provisional diagnosis-

CVA WITH LEFT UPPER LIMB AND LOWER LIMB PARESIS WITH ACUTE INFARCT IN THE  .

RIGHT CORONA RADIATA EXTEDING TOWARDS RIGHT TEMPORAL LOBE 

Treatment 

1. TAB. ECOSPIRIN 150 mg PO/OD/HS

2. TAB. CLOPIDOGREL 75 mg PO/OD

3. TAB. ATORVASTATIN 40 mg PO/OD/HS

4. PHYSIOTHERAPY OF LEFT UPPER LIMB



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