1801006048 - LONG CASE

 1801006048 - LONG CASE 



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Case:

This is a case of 55 year old male with chief complaints of
- deviation of mouth to left side since 5 days (11/03/2023)
- slurring of speech since 5 days


History of presenting illness:
Patient was apparently asymptomatic 5 days ago.
He then developed slurring of speech which was sudden in onset.He also developed bilateral blurring of vision which was sudden in onset and which lasted for an hour.On the same day his wife noticed deviation of mouth to left side and was taken to local doctor for which he was given ORS but the symptoms had not subsided.
The next day his wife took him to another doctor for which he was given ORS again.
On 13/03/2023 he came to the our hospital.
At the time of presentation 
- slurring of speech had decreased
-slight deviation of mouth was present 

No weakness of upper and lower limb
No h/o loss of consciousness 
No drooping of eyelids
No drooling of saliva
No difficulty in swallowing


Daily routine:
Patient is a farmer by occupation resident of yadgirigutta.
Patient wakes up at 5am in the morning and does his daily work and prays for an hour.
He has rice for breakfast by 8 am.
He goes to the fields along with his wife on scooty by 9am.
He has his lunch by 1pm.
In the evening they return from work at 6pm.
He goes for bath and has his tea.
He has rice for dinner at 8pm and prays for an hour.
He goes at bed at 10pm.


Past history:
No history of similar complaints in the past.
Patient is a known case of Hypertension since 1 year and does not take his medication regularly.
History of tuberculosis 21 years ago and was on medication for 6 months.
History of perforation to tympanic membrane 21 years back for which he has been using a hearing aid.
No h/o Diabetes,asthma,epilepsy

Personal history:
Diet: mixed
Apetite: normal
Sleep: disturbed
Bowl and bladder: regular
Addictions: drank sara when he was 20 years old and stopped when he was 30 years.

Family history:

Father is a known case of Diabetes Hypertension and he passed away due to COVID.

Mother passed away due to breast cancer

Both the sons of the patient were also affected with tuberculosis at the same time.


Brother had history of stroke 3 years back.


General examination:
Patient is conscious,coherant,cooperative,moderately built and moderately nourished.

Pallor:absent
Icterus:absent
Cyanosis:absent
Clubbing: absent
Lymphadenopathy:absent
Pedal edema:absent

Vitals:
Temperature: afebrile 
Pulse: 60 beats per minute
Blood pressure: 130/80 mmHg
Respiratory rate: 18 cycles per minute 

Systemic examination:

CVS: S1 & S2 heard. No murmurs 
Respiratory system:Normal vesicular breath sounds heard 
Abdomen: Soft and non-tender.No organomegaly


CNS:

   - Higher mental functions   

  • conscious,coherent and cooperative 
  • memory- able to recognize his family members 
  • Speech - comprehension present, no fluency, repetition present


  • Cranial nerve examination  
          
  • I- Olfactory nerve-  sense of smell present
  • II- Optic nerve- direct and indirect light reflex present 
  • III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis
  • V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.
  • VII- Facial nerve- face is symmetrical, forehead wrinkling present , nasolabial folds prominent on both sides.
  • VIII- Vestibulocochlear nerve- decreased hearing of the left ear ( rinner’s negative for 256 Hz and 512 Hz) and normal hearing of the right ear
  • IX- Glossopharyngeal nerve-  palatal movements present and equal
  •  X- Vagus- palatal movements present and equal
  • XI- Accessory nerve- sternocleidomastoid contraction present
  • XII- Hypoglossal nerve- deviation of tongue to right side and no fasciculations present
-Sensory system examination:

                                                        Right                           Left  
  • crude touch                         present                      present
  • fine touch                              Present                    present
  • pain                                        Present                   Present      
  • vibration                              Present                    Present        
  • temperature                        Present                    Present     
  • stereognosis                      Present                       Present 
  • 2 pt discrimination           Present                    Present         
  • graphaesthesia                  Present                      Present
 
                                                                                                                                                         R                                   Right.                                            Left  
    Motor system examination
      BULK:        U/L- arm        28cm                           29cm                                   
                                -forearm    27 cm                          26cm   
                                      
                           L/L- thigh        49cm                            49cm
                                  - leg           33cm                            31cm
                  
       TONE:     U/L                   normal                          normal
                        L/L                   Normal                         normal


                                                      Right                                  Left  

       POWER:       U/L-  hand          5/5                               5/5
                                      elbow         5/5                                   5/5
                                    - shoulder    5/5                                   5/5

                            L/L- hip              5/5                                   5/5
                                  - knee           5/5                                   5/5   
                                  - ankle          5/5                                   5/5





                                                           Right                            Left        
       REFLEXES:    Biceps                  ++                             ++
                                 Triceps                 ++                             ++
                                                                          
                                     Knee                ++ +                          +++
                                      Ankle               +                                 +
                              Plantar                 Flexion                  Flexion
















Investigations:

Complete blood picture-
 
Haemoglobin:11.7

Peripheral smear: normocytic normochromic anemia


Red blood cells:3.86


Pcv:34.6


Platelet count:2.10


Total leucocyte count:5,100

Fasting blood sugar : 92 mg/dl


Serum creatinine :1.3 mg/dl
Blood urea  38 mg/dl

CUE:

Colour : pale yellow

Appearance : clear

Reaction :acidic

Albumin:nil

Sugar: nil

Bile salts and bile pigments : nil

RBC : nil

Crystals :nil

Casts : nil

pus cells:2-3

epithelial cells-2-3

Serum electrolytes 

Sodium: 145 mEq/L

Potassium:4.2mEq/L

Chloride:104 mEq/L

Calcium ionized:1.11 mmol/L

ECG: 




MRI:





2D ECHO:





DRUGS :





Provisional diagnosis:

Cerebrovascular accident 
With acute infarct in left internal capsule
With acute infarct in left occipital lobe

Treatment:

INJ. OPTINEURON 1 AMP IN 500ML

NS IV OD 

TAB. CLOPITAB 75 MG PO/OD

TAB. ECOSPRIN AV 75/10 PO



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