A 65 year old male with weakness of left upper and lower limb

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 A 65 year old male who is a farmer by occasional came with complaints of weakness of left lower limb and left upper limb since yesterday and slurring Of speech since yesterday 

Tingling sensation of right upper limb and generalised weakness 20 days back

HISTORY OF PRESENTING ILLNESS-

Patient was apparently alright till 20 days back when he had c/o tingling sensation in right upper limb which gradually progressed f/b he developed generalised weakness for which he was taken to hospital and MRI was done which showed acute lacunar infarct and chronic lacunar infarcts and was treated conservatively. Since yesterday morning he has c/o tingling sensation of left upper limb and lower limb f/b he developed weakness of left side upper and lower limbs a/w slurring of speech.

PAST HISTORY-

H/o CVA (right hemiparesis) 6 years back 

H/o hypertension since 6 years on tab telmisartan 40mg + amlodipine 5mg

H/o dm since 5 yrs on Tab.Metformin 250 mg

H/o? hypertensive urgency 2 months back

ADDICTIONS: consumed alcohol regularly and stopped it 5 years ago

FAMILY HISTORY- none

PERSONAL HISTORY-

Appetite -normal

Bowel and bladder movements:normal

No allergies

GENERAL EXAMINATION-

Pallor- ab

Icterus- ab

Cyanosis- ab

Clubbing- ab

Pedal edema- ab

VITALS AT PRESENTATION:

Bp- 150/90mmhg

Pr-96

Rr- 17 cpm

Temp- 98.2F

SYSTEMIC INVESTIGATIONS-

CVS: s1s2 +

RS : BAE+


CENTRAL NERVOUS SYSTEM EXAMINATION.


Higher mental functions


          • conscious


          • oriented to person and place


          • memory - able to recognize their family members and recall recent events


          • Speech - no deficit


Cranial nerve examination 


          • 2- Direct and indirect light reflex present


          • 3,4,6 - no ptosis Or nystagmus


          • 5- corneal reflex present 

        

         • 7- no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present


          • 8- able to hear


          • 9,10- position of uvula is central


          • 11- sternocleidomastoid contraction present


          • 12- no tongue deviation


Motor system 


Reflexes 

                          Right               Left 

Biceps                 3+                   2+

Triceps                3+                   2+ 

Supinator           3+                   2+

Knee                   3+                   2+ 

Ankle                  2+                    + 

Plantar         Extension          Extension


Muscles power: 


                                       Right            Left 

Upper limb 

Elbow - Flexor                4/5             0/5 

            - extensor           4/5             0/5 

Wrist - Flexor                 4/5              0/5

          - extensor            4/5              0/5 

Hand grip                       4/5              0/5 


Lower limb                                           

Hip  - Flexors                  4/5              0/5 

      - extensors                4/5              0/5

Knee - Flexors                4/5              0/5

          - Extensors           4/5              0/5

Ankle - DF                       4/5              0/5

           - PF                       4/5               0/5

EHL                                  4/5               0/5 

FHL                                  4/5               0/5


Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are normal















MRI





PROVISIONAL DIAGNOSIS-

CVA (LEFT HEMIPARESIS) 

ACUTE INFARCT IN RIGHT SUPERIOR FRONTAL LOBE, RIGHT PARACENTRAL LOBULE

H/O CVA (RIGHT HEMIPARESIS) 6 YEARS BACK

TREATMENT:

TAB ECOSPIRIN 150 mg PO/ OD

TAB CLOPITAB 75 mg PO /OD

TAB ATORVAS 80mg PO/ OD/HS

Bp, temp, pr, rr charting 4th hrly

GRBS charting 6th hrly


SOAP NOTES 28/11/2022

S:

No fever spikes

Stools not passed


O:

Pt is C/C/C

BP: 140/80 mmhg

PR:89 bpm

Temp : 98.0 F

GRBS : 161

CVS: s1s2 +

RS : BAE+

CNS-HMF intact 

Pupils- b/l nsrl

Cranial nerves- N

Motor system- 

Tone    Rt.     Lt

   UL.     N.      N

    LL.     N.      N

Power     Rt.       Lt 

    UL.      4/5.      0/5

    LL.        4/5.      0/5


Reflexes   B.     T     S    K    A    PLANTAR

    RT.        3+   3+  3+   3+  2+  extension

    LT.         2+   2+  2+   2+   +    Extension

Sensory system- intact

A:

CVA (LEFT HEMIPARESIS) 

ACUTE INFARCT IN RIGHT SIDE CINGULATE GYRUS

H/O CVA (CHRONIC INFARCT IN LEFT BASAL GANGLIA) RIGHT HEMIPARESIS 6 YEARS BACK


P:

TAB ECOSPIRIN 150 mg PO/ OD

TAB CLOPITAB 75 mg PO /OD

TAB ATORVAS 80mg PO/ OD/HS

Bp, temp, pr, rr charting 4th hrly

GRBS charting 6th hrly

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