1702102050 LONG 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 UL 4+/5. LL 4+/5
Left UL 3/5. LL 3/5

Reflexes-  Right.         left
Biceps:.         +.            +++
Triceps:.        +.           +++   
Supinator:    +.            +++
Knee :            +.            +++
Ankle:           +.              +
Left extensor present (Babniski positive)

PROVISIONAL DIAGNOSIS
CVA with left hemiparesis (UMN type of Palsy) with acute infarct 
in Right ? MCA territory

INVESTIGATIONS






ECG

MRI BRAIN




DIAGNOSIS
CVA with left hemiparesis (UMN type of Palsy) with acute infarct 
in Right Parietal lobe and Frontoparietal lobe

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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