FINAL LONG
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Long case :
70 year old male who is a resident of Nalgonda who is survived with two kids caste to the casualty with complaints of :
1. Weakness of right upper limb and lower limb since 6 months
2. Slurring of speech since 6 months
2006: Patient was apparently asymptomatic 25 years back then he observed right lower limb weakness for which he was given home remedies and was subsided by 2 months was able to go to work by 2months
2013 : Patient had met with an RTA and sustained fracture to his left femur and was operated in Hyderabad underwent internal fixation .
After 6 months from this incident , he couldn’t go to work due to his fracture , his sons and wife would go for farming , and he would be at home taking rest , he started walking using walker , one night he went to a function in the near by village ate non -veg and drank alcohol 90ml and came back home and complained left sided chest pain to his sons and wife at 3:00pm and near by practice right was called for check up where he told his bop shoot up to 200/100mmhg , he advised for immediate hospital admission , due to lack of transport they got him to the hospital after 6 hours , by then he developed right hemiparesis and complainted of slurring of speech with deviation of mouth .
No History of Numbness, tingling. *Nausea, vomiting, diarhhoea, *Involuntary movements, * wasting/thinning , *Band like sensation , * low back ache , *cotton wool sensation *postural giddiness, palpitation, * seizure, *Head trauma , *loss of perception of smell, *Blurring of vision/ double vision * loss of sensation over face , *Difficulty in chewing food, * Abnormality in taste sensation.
PERSONAL HISTORY:
He wakes up at 5 am in the morning goes to the farm and work there till 8am and come back to home and freshen up for 1 hour eat and go back to work and comes back by 4 pm
His appetite was normal and takes mixed diet, sleep adequate, bowel and bladder movements were regular.
General examination:
Patient is conscious, non-coherent, co-operative ,oriented to person , moderately built and poorly nourished.
Pallor - Negative , Icterus- negative, No cyanosis ,clubbing ,Lymphademopathy, pedal edema.
VITALS:
Bp: 140/90 mmhg
Pr :80bpm regular normal volume in right supine position
spo2 :98%at room air
Temp :97°F
RR -18cpm
Grbs -136gm/dl
Cvs -s1 s2 heard,no murmurs
Rs -bae +,nvbs heard
P/a soft ,non-tender,
bowels sound heard
CNS:
HMF- patient conscious, orientation is not elicited
Speech- motor aphasia(+) .
No h/o delusions, hallucinations.
h/o emotion lability.
cranial nerves: Right left
1 st: smell Could be elicited
2nd :VA/colour-Vision: Couldn’t be elicited
3rd,4th,6th:
pupil size. N N
DLR/CLR. Couldn’t be elicited
No ptosis, nystagmus : Couldn’t be elicited
5th :
sensory: over face and buccal mucosa : Couldn’t be elicited
motor : mastication movements : Couldn’t be elicited
reflex : corneal and conjunctival (+)
Jaw jerk (-).
7th:
motor:
Nasolabial Lost on the right side Present on left side
Fold prominent.
Facial mov. Weakened Normal
sensory: Couldn’t be elicited
Secretomotor: moistness of eye +
Tongue : normal, buccal mucosa normal.
8 the nerve:
Rinnes : Couldn’t be elicited
Weber's: Couldn’t be elicited
9and 10 th nerve:
uvula centrally placed and symmetrical, gag and palatal reflex present
11 th nerve:
trapezieus : Couldn’t be elicited
sternocleidomastoid : Couldn’t be elicited
12th nerve:
tongue tone normal, no wasting, no fibrillations,no deviation of tongue.
MOTOR SYSTEM :
Right. Left
Bulk: Upper limb Normal Normal
Lower limb Normal Normal
Tone: Upper limb: Hypotonia Normal
Lower limb : Hypotonia Normal
Power: Upper limb : 0/5 5/5
Lower limb : 2/5 5/5
Reflexes:
Superficial reflexes:
Right. Left
Corneal- (+) (+)
Conjunctival- (+) (+)
Abdominal- (-) (-)
Plantar- Decreased Decreased
Muscle power :
Upper limb : Couldn’t be elicited
Lower limb : Couldn’t be elicited
Deep tendon reflexes :
Right. Left
Biceps. ++++ ++
Triceps. ++++ ++
Supinator. ++++ ++
Knee ++++ ++
Ankle. ++++ -
SENSORY SYSTEM:
Not elicited due to motor aphasia.
CEREBELLUM:
titubation - absent
Nystagmus- absent
Intensional tremors - absent
Hypotonia-no
Pendular knee jerk : Couldn’t be elicited
Dysdiadokinesia : Couldn’t be elicited
MENINGIAL SIGNS:
Neck stiffness - negative
Kernigns sign - negative
Brudzinkis sign - negative
PROVISIONAL DIAGNOSIS
Acute ichaemic stroke with denovo RVD+
INVESTIGATIONS
HAEMOGRAM
Hb-13.3 gm/dl
TLC- 9,200
58/30/04/06/00
PCV- #39.8
MCV-88.2
MCH-29.4
MCHC-33.3
RBC COUNT-4.52 million/cu mm
PLATLETS COUNT- 3.24 lakhs/cu mm
BLOOD GROUP- B +ve
BT- 2 MIN 30 SEC
CT - 4 MIN 30 SEC
RFT
Urea-19
Creat-0.9
Uric acid-5.0
Ca-1.02
Phosphorus -3.2
Na- 138
K- 3.5
Cl-10.6
LFT
Total bilirubin -#1.13 mg/dl
Direct-#0.58mg/dl
AST- #56
ALT-#79
Alkaline phosphatase -#1053
Albumin-3.41
RBS -#87 mg/dl
FINAL DIAGNOSIS
Acute ischemic stroke in parietal, temporal and frontal regions with RVD+
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