LONG CASE.

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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


Di

rect-#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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