65 year old male patient with right sided hemiparesis

 

CASE: 

A 65 YEARS OLD MALE came to the OPD with:

CHIEF COMPLAINTS:

1. Difficulty in lifting right upper limb and lower limb since 3days.
2. Deviation of angle of mouth towards right since 3days.
3. Difficulty in swallowing liquids and solids since 3 days
4. Fever since 5 days, not associated with chills and rigors, vomitings, headache .
5. Cough since 3 days, productive in nature.

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 7 years ago then he had dinner around 8pm and slept, at 2pm he woke up to pass urine he suddenly fell in the bathroom following which he had right side hemiparesis for which he went to a private hospital and was diagnosed  with CVA and HYPERTENSION, given medication and discharged.

The patient took ?medications for 1year and stopped taking them, took physiotherapy for 1 month it took 3months to walk but did not recover completely and  since then uses cane to walk.

The patient was started on ANTI HYPERTENSIVES ? which he used for one year.

No slurring of speech during this episode.

No loss of consciousness.

Later he took his medications on and off till 1 year ago since then he completed stopped taking medication.

On 6/02/2022,

Patient went to use washroom around 5am and was not able to get up after passing urine.

Slurring of speech was present,Deviation of angle of mouth towards right, 

Dysphagia, right side hemiparesis.

He was taken to a private hospital andwas admitted there for three days, took an CT BRAIN impression:

1. Ill-defined patchy hypodensity in left body of caudate nucleus and left corona radiata - ?subacute to chronic infarct. 
2. Chronic lacunar infarcts in bilateral capusloganglionic regions and bilateral corona radiata.
3. Diffuse cerebral atrophy.
4. Chronic small vessel ischemic changes.

Then was referred here for further treatment.

PAST HISTORY:

No h/o similar episodes in past.

Not a k/c/o DM, TB, Asthma, Epilepsy.

PERSONAL HISTORY:

DAILY ROUTINE before illness:

• 5am- wakes up and get ready
• 7am- Tea
• 10am- breakfast
• 12pm- goes to work (goatherd)
• 6pm- come back home and cleans up
• 8pm- dinner
• 9pm- sleeps

after illness: patient has the same routine as before, but has difficulty in walking.

1. Diet- Mixed
2. Appetite- Normal
3. Bowel- regular, passed stools  3 days ago ; bladder movements- Regular.
4. Sleep- Adequate
5. Addictions- H/o alcohol consumption 90ml/day for 20years 7 years ago ,since then consumes occasionally.
6. Surgical history- Cataract surgery in both eyes 8 years ago

FAMILY HISTORY: 

Insignificant

GENERAL EXAMINATION:

The patient was examined in a well-lit room after informed consent was taken.

He is conscious, non -coherent, cooperative, well oriented to time, place and person. He was well nourished and moderately built.

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.

VITALS:

1. PR: 92bpm
2. RR: 22cpm
3. BP: 110/90 mmHg
4. Temperature: 99°F
5. GRBS: 94mgdL
6. SpO2: 95% on room air.

SYSTEMIC EXAMINATION:

CNS:

HIGHER MENTAL FUNCTIONS:

• Oriented to time,place,person
• Memory : immediate,recent, remote intact
• Speech: slurred
• No delusions or hallucinations

CRANIAL NERVES: 

1- not tested

2- counting fingers+

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

 

7-deviation of Angle of mouth to right side.

8- Normal hearing

9,10-difficulty in swallowing and slurred speech, gag reflex not tested

11,12- normal.

MOTOR EXAMINATION:

TONE: Increased in right upper and lower limbs and  normal in left upper and lower limbs 

POWER :                    Right       Left

     

    Upper limb          4/5             4/5

    Lower limb          3/5             4/5

Reflexes :                 Right                Left

1. Biceps:             3+                      2+
2. Triceps:           3+                      2+
3. Supinator:      3+                       2+
4. Knee:               3+                       2+
5. Ankle:               -                         -

Plantars:            extensor          Flexor

SENSORY EXAMINATION:

Could not elicit.

CEREBELLUM EXAMINATION:

• Able to do finger nose test.
•  Dysdiadokinesia present
• No rebound tenderness 
• Gait: couldn't walk , CIRCUMDUCTION PATTERN (as patient's attenders described)

AUTONOMIC NERVOUS SYSTEM:

• No abnormal sweating
• No resting tachycardia

MENINGEAL SIGNS: Absent

 

CVS:  S1 and S2 heard.

RS: BAE+ NVBS+

Per Abdomen:

Soft, non tender, no distension, umbilicus is central and inverted,no scars, no sinuses.

 

INVESTIGATIONS:

HEMOGRAM 

1. Hb- 15.4g%
2. TLC- 8,700 cells/cc
3. Neutrophils-78
4. Lymphocytes- 12
5. Eosinophils-2
6. Monocytes-8
7. Basophils-0
8. PCV-43.7
9. MCV- 37.8
10. MCH-30.9
11. MCHC-35.2
12. RDW-CV- 13
13. RDW-SD- 42.5
14. RBC- 4.98m/cc
15. Platelets- 2.18lakh
16. PS- NORMOCYTIC NORMOCHROMIC

LFT

1. TB- 2.11
2. DB- 0.94
3. AST- 41
4. ALT- 26
5. ALP- 98
6. TP- 7.4
7. ALB- 3.83
8. A/G- 1.07

RFT

1. Serum urea- 22
2. Serum creatinine- 1.1
3. Na+: 135
4. K+: 4.1
5. Cl- 98

SEROLOGY

1. HIV- NEGATIVE
2. HBsAg- NEGATIVE
3. HCV- NEGATIVE

ECG

COLOUR DOPPLER 2D ECHO

CAROTID DOPPLER

THYROID PROFILE

PROVISIONAL DIAGNOSIS:

 Subacute ischemic CVA stroke 

TREATMENT:

1. Tab. CLOPITAB 75mg PO/OD
2. Tab. ECOSPRIN 75mg PO/OD
3. Tab. ATORVA 20mg PO/OD
4. RT feeds 4th hourly 100ml milk and 200ml water
5. BP/PR/RR/ Temp. Charting 4th hourly
6. Tab. PAN 40mg PO/OD
7. Inj. OPTINEURON 1amp in 500ml NS/IV/OD