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Here is a case I've seen:
A 60 year old woman was brought to the hospital by her daughter 1 day back with the chief complaint of sudden onset weakness of upper & lower limbs since 2 days.
History of present illness:
The patient was apparently asymptomatic 2 days back,then developed sudden onset weakness of limbs( Rt > Lt )followed by tingling sensation and numbness of lower limbs,which progressed to upperlimbs,non progressive,lasted for 2-3 hrs, then recovered spontaneously.
H/O inability to talk for 2-3 hrs, resolved spontaneously
No H/o LOC,nausea,Vomitings,blurring of vision, involuntary micturition/defecation.
Difficulty in raising right arm above head,mixing food and combing hair since 1 day.
no h/o headache, deviation of mouth/tongue,
no difficulty in swallowing,
no h/o involuntary movements
No h/o loss of pain, temperature
On the day of admission,at around 7:30pm pt. developed sudden onset giddiness on getting up from bed,a/w slurring of speech,drowsy but arousable,not oriented; with 1 episode of involuntary micturition
She developed deviation of mouth to left side.
PAST HISTORY:
K/c/o HTN since 5 years and is on T.Amlodipine 2.5mg OD, stopped taking medication since 5 days
H/O of pain in both knees since 10years,on Ayurvedic medication.
No h/o diabetes mellitus, epilepsy , bronchial asthma, chronic heart and kidney diseases, tuberculosis, thyroid disorders.
No H/o previous surgeries and blood transfusion.
PERSONAL HISTORY:
Diet: mixed
Appetite: normal
Sleep: adequate
Bowel and bladder movements: regular.
No addictions,occasional toddy drinker.
Menstrual hx: insignificant
Marital hx: married at the age of 11 yrs, has 6 children(4 daughters& 2 sons)
Lives with son and his family.
FAMILY HISTORY:
No significant family history.
DRUG HISTORY:
Not allergic to any known drugs.
GENERAL EXAMINATION:
Patient is conscious, coherent and cooperative
E4V5M6
Moderately built and moderately nourished.
No signs of pallor, icterus, cyanosis , clubbing, kilonychia, generalised lymphadenopathy, bilateral pedal edema.
VITALS:
Temperature: afebrile
Pulse rate: 90 beats per min
BP: 190/120 mm of hg
RR: 18 cycles per min.
Sp02 : 98% at room temperature
GRBS: 106 mg/dl
SYSTEMIC EXAMINATION:
CNS
Higher mental functions:
pt.is conscious,oriented to time, place,person. Alert with slurred speech.
Remote & recent memory - intact
Pupils - NSRL
Spinomotor :
no wasting/ thinning of muscles. No pain, fatigue and fasciculations.
Right Left
Bulk :
Upper limb Normal Normal . Lower limb . Normal. Normal
Tone:
Upper limb:. Normal. Normal .
Lower limb:. Normal. Normal .
Power:
Upper limb:. 3+/5. 5 /5
Lower limb:. 3/5. 5/5
Hand grip : 50% . 100%
following commands
Motor system
Reflexes:
Superficial reflexes: normal
Deep tendon reflexes:
Biceps:. 3+. 2+
Triceps:. - 2+
Supinator:. -. 1+
Knee:. -. -
Ankle:. -. -
Plantar:. Mute Withdrawal
Sensory system: right Left
Fine touch + +
Vibration + +
Position sense + +
Crude touch + +
pain and temperature + +
Rhomberg's - absent
Cerebellum:
Nystagmus -ve
Pendular knee jerk -ve
Rebound phenomenon -ve
Dysdiadochokinesia -ve
Finger nose incoordination-ve
Finger finger incoordination-ve
Gait - normal
Cranial nerve examination:
I : intact
II : visual acuity 6/6
Colour vision normal
III,IV,VI : normal pupil size
No nystagmus,ptosis,eyemovements normal
V: Sensory - normal
Motor - normal
Corneal & conjunctival reflexes - normal
Vll: Deviation of angle of mouth towards left, Able to close eyes.
frowning present on both sides of forehead
VIII : normal.
IX,X: Uvula- not visualised,gag reflex +
XI: normal
XII: tongue- tone normal,no deviation
ANS:regular bladder movements. No sweating and palpitations.
Meninges: no signs of meningeal irritation(fever, headache, neck stiffness, nausea and vomitings)
PERABDOMINAL EXAMINATION:
Shape of abdomen: scaphoid
No tenderness and local rise of temperature.
No palpable masses.
Hernial orifices normal.
No free fluid and bruit.
Liver and spleen : not palpable.
Bowel sounds: normally heard.
RESPIRATORY SYSTEM:
Position of trachea: central
No wheeze and dyspnea.
Bilateral air entry present.
Normal vesicular breath sounds heard.
No adventitious sounds.
CVS:
S1 and S2 heard.
No murmurs.
Based on the clinical findings,the following investigations were sent:
CBP
CUE
RFT
USG ABDOMEN
RBS
ECG
FUNDOSCOPY- normal
CT BRAIN
MR Angiography
Day 1
CT BRAIN
MR ANGIOGRAPHY
CVA(ischaemic) with Right sided Hemiparesis (resolving) 2° to infarct
in ? MCA territory
? Left lentiform nucleus
K/C/O HTN
Treatment:
1. Ryle's tube feed - 200ml milk 2nd hourly
100 ml water hourly
|
Day 3 - oral feeding
2. INJ MANNITOL 20mg/IV/TID
3. T. PAN 40mg OD
4. T. ECOSPIRIN 75mg OD
5. T. CLOPIDOGREL 75mg OD
6. T.ATORVAS 20mg H/S
7. Physiotherapy for right UL & LL
8. Frequent mobilization
9. Vitals monitoring hrly,I/O charting
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