50/M with Left hemiplegia

 06/09/2023

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Khushi Tulsyan, Intern

Roll no. 49

DOA - 06/09/2023

CKD Ward

Chief Complaint-

C/o weakness of left u/l and l/l since 2 days

C/o deviation of mouth towards right since 2 days

HISTORY OF PRESENTING ILLNESS-

Pt was apparently asymptomatic alright 2 days back. Then he had weakness of left UL and LL sudden in onset and deviation of mouth towards right since 2 days

Pt is unable to lift his hand above head 

No involuntary movements, no involuntary micturation/defecation

Able to swallow food , chew food 

No headache ,  No blurring of vision

No vomitings , no loose stools

PAST HISTORY-

N/K/C/O DM 2 , HTN , TB , Epilepsy, CVA ,CAD

PERSONAL HISTORY-

Diet - Mixed

Appetite - Normal

Bowel and Bladder movements- Regular

Sleep - Adequate 

Addictions - 150 ml alcohol daily

He is a labourer by occupation 

FAMILY HISTORY-

Not significant

GENRAL EXAMINATION-

Pt is c/c/c well oriented to time place and person 

No signs of pallor icterus cyanosis clubbing lymphadenopathy edema 

Temp - Afebrile

PR - 78 bpm

RR - 24 cpm

BP - 110/70 mmhg

Spo2 - 96 RA

GRBS - 119 mg%

CLINICAL PICTURES-

SYSTEMIC EXAMINATION-

CVS -

S1 S2 +

No thrills felt

No murmurs heard

RS -

B/l air entry +

Position of trachea central

No wheeze or rhonchi

P/A-

Shape - scphaoid

No tenderness or organomegaly present

CNS-

He is conscious 

Speech is slurred

No signs of meningeal irritation 

Motor System-

GCS 15/15 - E4V5M6

Power-

                           R.          L. 

U/l                     5/5.       1/5

L/l.                    5/5.       1/5

Tone-

U/l.                   N.          N

L/l.                    N.          N

Reflexes-

B.                      2+.        2+

T.                       1+.         1+

K.                      2+.        2+

A.                      1+.         1+

Plantar        Flexor.    Extensor

PROVISIONAL DIAGNOSIS-

Acute CVA with Ischemic stroke in ? Rt MCA Territory with Left Hemiplegia

INVESTIGATIONS-

06/09/2023:

ECG -

Hb - 12.3 NCNC

Tlc - 7400

Plt- 1.2 lakhs/cumm

MCH - 36.1

MCV - 97.1

RBS - 90 mgdl

S. Urea - 22

S. Creat - 1

Na - 131

K - 3.9

Cl - 98

Ca - 1.1

MRI. -

Acute infarct in Right parietal cortex, right inferior temporal lobe, right caudate nucleus and right lentiform nucleus -right MCA territory infarets.

Few acute lacunar infarets in right parietal lobe.

MR angiogram sequences show stenosis of right ICA with non- visualization of right MCA.

Treatment Given-

IV Fluids NS @100 ml/hr

Inj Thiamine 200mg in 100 ml NS IV/BD

Tab Ecosprin AV 75/10 PO/HS

Inj Manitol 100 ml IV/OD

Physiotherapy