1702102017 SHORT CASE

A 85 year-old man, who is a farm worker by occupation, presented to the hospital with

-Weakness of left upperlimb and lowerlimb since 20 days
-Difficulty in swallowing since 20days 
-Deviation of mouth towards left side since 20 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 20 days back, he had sudden onset of weakness of left upper limb and lower limb which was noticed by his attender, when he tried waking up from bed he couldnt get up and complained of weakness and was went to a near by RMP and was sent to our hospital for further management. 

No h/o trauma, no c/o giddiness, headache, chest pain, burning micturition, pedal edema. No c/o nausea, vomiting.PAST HISTORY

- Known case of hypertension since 3 years 

- Not a known case of Diabetes mellitus, Asthma, Epilepsy


PERSONAL HISTORY

-Mixed diet of veg and non-veg food

-Appetite Inadequate

-Bowel movements- normal. No history of involuntary defecation

- Urine output- normal. No history of involuntary urination

-Patient is an alcoholic since 20 years

-Chronic smoker (4-5 chutta/day) since 20 years 

-Patient stopped smoking and drinking 2 months ago

TREATMENT history

-Patient is on antihypertensives since 3 years


GENERAL EXAMINATION
- Patient is conscious, coherent and cooperative
- Pallor- Yes
- Cyanosis- No
- Lymphadenopathy- No
- Clubbing of fingers- No
- Pedal edema- No
Temperature- Afebrile
Pulse rate- 100/ min
Blood pressure- 140/90 mmhg
Respiratory rate- 22 cycles per min
SPO2- 99 % at room air
CVS- S1 and S2 heard 

Respiratory system
NVBS present 

CNS 
Conscious 
Speech - normal
No signs of meningeal irritation
Tone- Increased in left side
Power- 
 Right. left
 4+/5. 4+/5
Reflexes-
Right. left
Biceps:. +. +++
Triceps:. +. +++
Gait         
Supinator:. +. +++
Knee : +. ++
Ankle:. +. +
Left extensor present (Babniski positive)

PROVISIONAL DIAGNOSIS
CVA with left UMN Palsy with acute infarct 
in Right Parietal lobe and Frontoparietal lobe
INVESTIGATIONS :-
Hemoglobin -11.8 gm/dl
Tlc-7000
Platelets- 2lakhs

Blood urea :-26mg/ dl
Serum creatinine :- 1.3 mg/ dl
Serum electrolytes:-
Na-136
K-4.2
Cl-99

ECG:-
Mid brain:-

TREATMENT:

RT FEEDS 100 ML MILK - 2ND HOURLY , 100ML HOURLY
2) INJ PAN 40 MG /IV/OD
3) INJ OPTINEURON 1 AMP IN 100 ML NS /IV/OVER 30 MIN
4)TAB ASPIRIN 100 MG RT/OD
5)TAB CLOPIDOGREL 75 MG RT /OD/H/S
6) TAB ATORVASTATIN 40 MG /RT/OD/HS

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