1801006118 - LONG CASE

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 A 50 year old male, resident of Miryalagudem ,  ice factory worker by occupation presented with the chief complaints of 

Weakness in the right upper and lower limbs since 7 days

 slurring of speech and deviation of mouth to the left since 7 days

HISTORY OF PRESENT ILLNESS:-

Patient was apparently asymptomatic 1 month back later developed giddiness and weakness of right upper and lower limbs followed by fall and diagnosed with hypertension during hospital admission.

Patient then developed sudden onset of weakness in the right upper and lower limb while going to washroom and he was swaying towards right side and unable to walk, associated with deviation of mouth towards left side and slurring of speech after few minutes and taken to the local hospital then referred to our hospital on next day morning.

Upper limb- Patient has difficulty in combing hair,  difficulty in buttoning and unbuttoning

Lower limb- not able to stand due to swaying towards right side

No H/o difficulty in lifting the neck, rolling over the bed and no difficulty in breathing

No h/o tingling and numbness, patient is able to feel his clothes.

No H/o loss of consciousness, altered sensorium and headache, seizures and bowel and bladder disturbances

No complaints of memory or sleep disturbances and delusions

No H/o diplopia, blurred vision, drooping of eyelids, able to chew food and  no difficulty in swallowing 

Patient has no difficulty in closing eyes , lips, able to sense taste and able to move neck and tongue

No H/o fever, vomiting, headache , neck stiffness or any trauma to the head.

PAST HISTORY:-

Known case of hypertension since 1 month

Patient started using medication for hypertension for 20days and stopped for next 10days.

Not a known case of diabetes, asthma, tuberculosis, epilepsy, thyroid abnormalities,coronary artery disease.

PERSONAL HISTORY:- 

Daily routine:

Wakes 4am in the morning and stays close to his workplace, breakfast around 8-9am, lunch around 2pm usually takes rice and curry in his meals and consumes chicken/mutton twice weekly. He comes home by 6pm evening and sleeps by 9pm

Diet - mixed

Appetite- normal

Bowel and bladder movements - regular

Adequate sleep

Patient consumes alcohol since last 20years and chewing tobacco since last 10years.

1 packet for 2days

DRUG HISTORY:-

Takes medication for hypertension- Atenolol and amlodipine for 20days after diagnosed with hypertension and stopped for next 10days.

FAMILY HISTORY:-

No similar complaints in family 

GENERAL EXAMINATION:-

Patient was conscious, coherent, cooperative, well oriented to time, place and person.

Moderately built and well nourished.

Vitals-

BP : 140/90mm Hg

Pulse rate : 74bpm, normal volume, regular 

Respiratory rate : 15cpm

Temp : Afebrile to touch

No pallor , icterus, cyanosis, clubbing, lymphadenopathy, edema.

No neurocutaneous markers

SYSTEMIC EXAMINATION:-

CNS EXAMINATION:-

Higher mental functions intact- conscious, oriented to time place and person

Speech - no aphasia , dysphonia, dysarthria

Fluency, repetitions, naming - intact

No delusions and hallucinations 

No signs of meningeal irritation 

GCS scale - 15/15

Gait - walks with support 

Cranial nerves:-

1 no alternation in smell

2  visual activity normal

3,4,6 - eye movements in all directions

5 - normal sensations on face , mastication- normal, corneal reflex - normal

7 - deviation of mouth towards left side

8 - no hearing impairment, vertigo and nystagmus absent

9,10 - no difficulty in swallowing , no deviation of uvula, gag reflex +

11 - normal neck movements 

12 - tongue movements normal, no deviation of tongue

Pupils - normal in size , reactive to light 

Motor system

Bulk

TONE :

          Rt                 Lt

UL    Increased    N

LL     Increased    N

POWER:- 

          Rt    Lt

UL    4/5   5/5

LL    4/5    5/5

REFLEXES:

                  Rt         Lt

Biceps      +++       ++

triceps      +++        ++

supinator   ++          ++

knee          +++        ++

ankle         +++        ++

plantar     extension  flexion

Gait - not able to walk properly , need support while walking

Involuntary movements - absent 

Fasciculation - absent

SENSORY SYSTEM- 

Pain, temperature, crude touch, pressure sensations normal

Fine touch, vibration, proprioception normal

No abnormal sensory symptoms 

Cerebellum - 

Finger nose test normal,  no dysdiadochokinesia, no intentional tremor, Romberg test could not be done

Spine and cranium - no deformities

 CVS EXAMINATION :-

JVP: Normal

INSPECTION:

Chest wall symmetrical

Trachea central 

 PALPATION:

Apical impulse felt 

Thrills absent

 

PERCUSSION:

No abnormal findings

 

AUSCULTATION: 

S1, S2 heard

No murmurs 

ABDOMINAL EXAMINATION :- 

INSPECTION:

Flat shaped, free flanks , umbilicus central and normal in shape, hernial orifices normal

PALPATION:

 Abdomen is soft and non tender, no hepatomegaly, no splenomegaly 

Kidneys not enlarged, no renal angle tenderness

PERCUSSION:

Fluid Thrill/Shifting dullness/Puddle’s sign absent

AUSCULTATION:

Bowel sounds – normal 

No bruits

RESPIRATORY EXAMINATION :- 

Chest bilaterally symmetrical, all quadrants

moves equally with respiration.

Trachea central, chest expansion normal.

 Resonant on percussion

Bilateral equal air entry, no added sounds heard.

 Normal Vesicular Breath sounds heard.

Norm vocal resonance.

Vocal Resonance - normal

PROVISIONAL DIAGNOSIS:-

Acute Cerebrovascular accident ,mostly infarct in left internal capsule involving left MCA territory 

INVESTIGATIONS:

Anti HCV antibodies rapid - non reactive 

HIV 1/2 rapid test - non reactive

Blood sugar random - 109 mg/dl 

FBS - 114 mg/dl

Haemoglobin- 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

USG:-

Doppler:-

TREATMENT:- 

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