long case

1801006033 -.LONG CASE

CASE:

CHIEF COMPLAINTS:

50 Years old male ,resident of miryalaguda,works in ice factory, came with chief complaints of right sided weakness (upper limb and lower limb) , deviation of mouth to left side and slurring of speech since 3 days (12/3/2023 at 4 am).

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1month back then he developed giddiness and weekness in left lower limb and left upper limb(lowerlimb> upper limb), so he went to the hospital , there he diagnosed with hypertension,they gave antihypertensives (amlodipine and atenolol).his left sided weekness was resolved in 3 days.he took the antihypertensives for 20 days and after that he stopped medications since 10 days onwards because his friends told that take alcohol it will resolves the weekness of limbs. So he stopped medications and took the alcohol since 10 days.on 11/3/2023 night also he took alcohol and slept , on 12/3/2023 at 4am he woke up but he developed giddiness, unable to stand  due to weekness in the right upper and lower limbs, deviation of mouth to left side and slurring of speech. So he was taken to the miryalaguda hospital there he underwent CT scan then they referred to our hospital.he came to our hospital on 13/3/2023.

There is no history of difficulty in swallowing, behavioural abnormalities, fainting, sensory disturbances, fever, neck stiffness, altered sensorium, headache, vomiting, seizures, abnormal movements, falls.

DAILY ROUTINE:

Daily he wake up at 4:00am does his morning routine and drinks tea and goes to work ,at 9 '0 clock he comes to home and have breakfast and goes to work till  2 pm and will have his lunch at home ,he then again goes to work till 9pm returns home will have his dinner and sleeps at 10pm.

PAST HISTORY:

Fracture near the right elbow due to fall from the tree 30 years ago ,so he cannot extending his right hand completly.

He is a known case of hypertension since month.

Not a k/c/o Diabetes,asthma, coronary artery diseases,epilepsy,thyroid disorders.

PERSONAL HISTORY:

Diet- mixed

Appetite - normal

Sleep -normal

Bowel and bladder -regular

Addictions-

-He is chronic alcoholic since 30 years, stopped 3 years back but again started 6 mns back after death of  his daughter's husband.

-he chews tobacco since 10 years (1 packet per 2 days).

FAMILY HISTORY:

No similar complaints in the family.

TREATMENT HISTORY:

He is on antihypertensives (amlodipine and atenolol) since 1month and stopped from last 10 days.

GENERAL EXAMINATION:- 

-Patient is conscious, cooperative, with slurred speech 

Well oriented to time, place and person

-Moderately built and moderately nourished.

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 

Vitals :- 

Temp - afebrile

BP - 140/80 mm Hg

Pulse rate - 78 bpm

Respiratory rate - 14 cycles per minute 

SYSTEMIC EXAMINATION:

1) CNS EXAMINATION :-

Dominance - Right handed

Higher mental functions

 • conscious

 • oriented to time,person and place

 • memory - immediate,recent,remote intact

 •slurring of speech

Cranial nerves - 

I - no alteration in smell

II - no visual disturbances

III, IV, VI - eyes move in all directions

V - sensations of face normal, can chew food normally 

VII - Deviation of mouth to the left side, upper half of left side and right side normal 

VIII - hearing is normal, no vertigo or nystagmus 

IX,X - no difficulty in swallowing 

XI - neck can move in all directions 

XII - tongue movements normal, no deviation

Power:-

Rt UL - 4/5 Lt UL-5/5

Rt LL - 4/5  Lt LL-5/5

Tone:-

Rt UL - Increased

Lt UL- Normal

Rt LL- Increased

Lt LL- Normal

Reflexes: 

                   Right                    Left

Biceps:      +++                    ++

Triceps:       +++                    ++

Supinator:  +++                    ++

Knee:         +++                    ++

Ankle:            +++                    ++

Plantar:                              Flexion

Involuntary movements - absent

Fasciculations - absent

Sensory system - 

-Pain, temperature, crude touch, pressure sensations,Fine touch, vibration, proprioception -normal 

-two point discrimination -able to discriminate and tactile localisation -able to localise.

Cerebellum - 

Finger nose test normal, no dysdiadochokinesia, Rhomberg test could not be done

Autonomic nervous system - normal

• Meningeal sign -no meningeal sign

ABDOMEN EXAMINATION:

Inspection -

Umbilicus - inverted

All quadrants moving equally with respiration

No scars, sinuses and engorged veins , visible

 pulsations.

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 

hloride - 104 mEq/L

Calcium ionised - 1.02 mmol/L

*Thyroid function tests:

T3 - 0.75 ng/ml 

T4 - 8 mcg/dl 

TSH - 2.18 mIU/ml

*Anti HCV antibodies rapid - non reactive ;

*HIV 1/2 rapid test - non reactive 

MRI

 

CONFIRMED DIAGNOSIS:

Cerebrovascular accident with Right sided hemiparesis ,

Acute infarct in posterior limb of internal capsule.

TREATMENT:

Inj. OPTINEURON in NS 100 ml

Tab. ECOSPRIN

Tab. CLOPITAB

Tab. ATOROVASTAT

Tab. STAMLO BETA

Physiotherapy