1801006199 - LONG CASE

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Case discussion 

A 50 year old male presented to the casualty with weakness of right upper and lower limbs since the morning of 13/3/23 4am. With slurring of speech and deviation of mouth to the left side. 

 

History of presenting illness 

Patient was apparently asymptomatic 1 month back, he later developed giddiness followed by a fall. He was diagnosed with hypertension( HTN) to which he used medication for 20 days and stopped 10 days ago. 

He was asymptomatic until yesterday when he noticed weakness in his right upper and lower limbs while going to the washroom. It was associated with deviation of the mouth to left side and slurring of speech. Symptoms were sudden in onset and quick in progression.  

There is history of (H/O) trauma

There is no H/O difficulty in swallowing, giddiness, headaches, nausea, vomiting, drug intake, chest pain, drug intake, tingling sensation of effected limbs. 

Past history

Diagnosed with HTN one month back.

H/O past trauma

No H/O diabetes mellitus, epilepsy, tuberculosis, coronary artery disease, thyroidal illness, HIV, malignancy, fever, drug intake

No previous hospital admissions

 

Personal history

Diet- mixed

Appetite- normal

Bowel and bladder- regular

Sleep- adequate

Addictions- consumes alcohol( average of 90ml per day)

 

Family history- no relevant family history

 

General examination

Consent of the patient was taken

Patient is conscious, coherent and cooperative

Well built and nourished

pallor: absent

Icterus: absent

Cyanosis: absent

Clubbing:absent

Lymphadenopathy: absent

Edema: absent

Temperature: 98°F 

Pulse:60 beats/ minute

Blood pressure: 140/80mmHg

Respiratory rate: 14 cycles/minute

No involuntary movements

No abnormal neck swellings

No neck stiffness present

 

Systemic examination

CENTRAL NERVOUS SYSTEM

*Higher mental functions

Patient is conscious

Oriented to time place and person

Well dressed, well behaved and in a good mood

Speech slightly slurred, language understandable

Memory: intact

 Right handed person

*Cranial nerves

Olfactory nerve: smells perceived

Optic nerve: counting fingers 6m

III, IV, VI: ocular motility normal, pupillary reflexes normal

Trigeminal nerve: jaw jerk present, corneal reflexes present

Facial nerve: mouth deviated to the left side

Vestibulocochlear nerve: normal sensory hearing

IX, X: no difficulty in swallowing

Accessory nerve: neck movements normal

 

*Motor system

No muscle wasting

Normal muscle tone

Power: upper limbs- right 3/5.  Left-5/5

              Lower limbs- right 3/5. Left- 5/5

Reflexes.                         Right.            Left

             Supinator-          3.                     5

              Biceps.                 3.                     5

              Triceps.               3.                      5

              Knee.                    3.                      5

              Ankle           .         3                      5

Coordination

        Finger to nose- normal 

        Dysdiadochokinesia- normal

        Knee to hell- normal

Sensation- pain, temperature, proprioception, vibration felt equally on both sides

Gait- unable to walk without support, dragging the right leg

Romberg's test- couldn’t be elicited

CARDIOVASCULAR SYSTEM. 

*Inspection- normal shape, bilaterally symmetrical, no percardial bulge, no engorged veins

*palpation- apical beat felt at 5th inter coastal space, no additional pulsation felt, no thrills felt

*percussion- heart borders noted

*auscultation- S1 and S2 heard. No additional heart murmurs

 

ABDOMEN

*inspection- flat abdomen with no distension, no engorged veins visible, skin over abdomen normal, umbilicus central, hernial orifices normal, external genital normal.  

*palpation- no tenderness present, temperature to touch normal, no abnormal swellings. 

*percussion- tympanic sound with dullness over solid organs

*auscultation- bowel sounds heard. 

 

RESPIRATORY SYSTEM 

*inspection-chest normal shape and bilaterally symmetrical

*palpation-trachea midline, chest movements symmetrical, tactile and vocal fremitus felt

*percussion- no dullness present bilaterally 

*auscultation: Normal vesicular breath sounds heard, no added sounds. 

 

Diagnosis: Cerebrovascular accident with right hemiparesis most probably involving left internal capsule

 

Investigations:

 

Haemogram:

Haemoglibin 13.4

Total lecucocyte count 7,800

Red blood cells 4.45

Platelets- 3.01

 

Complete urine examination 

Pale yellow clear

Acidic

Trace albumins

Pus cells 3-4

Epithelial cells 2-3

Sugars nil

 

Thyroid function tests 

T3 0.75

T4 8

TSH 2.18

Renal function test

Urea: 19mg/dl

Serum. Creatinine: 1.1mg/dl

S. Na+: 141 mEq/L

S. K+:. 3.7 mEq/L

S. Cl-: 1.02 mmol/L

 

FASTING BLOOD SUGAR: 114mg/dl

 ECG:

Chest X-ray PA view:

MRI Brain:

Final diagnosis:

Acute infarct in posterior limb of lt internal capsule and old lacunar infarct in lt side of pons and few microhemorrhages noted in b/l cerebral hemisphere

 Treatment: 

1. TAB. ECOSPRIN 150 MG PO/STAT

2. TAB. CLOPITAB 150 MG PO/STAT

3. TAB. ATORVAS 80 MG PO/STAT

4. PHYSIOTHERAPY OF UPPER AND LOWER LIMB

5. I/O CHARTING