45 year old male patient with left hemiplegia

 June 3 2023

General medicine

M.Devisree gupta

Roll no 81 

Case of hemiplegia

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A 45 years old male Patient came to the casuality with complaints of deviation of mouth to right side since 27/5/23 night(after taking alcohol),weakness of left upper limb and lower limb since morning (28/5/23).

History of presenting illness:

Patient was apparently asymptomatic till 27/5/23 night ,then he developed deviation of mouth towards right side and on 28/5/23 morning had difficulty in walking due to which they visited a local hospital and was treated conservatively but symptoms did not subside and weakness progresses .

No h/o drooling of saliva.

-No h/o of loss of consciousness, nystagmus .

-No h/o of head trauma .

-h/o of low grade fever since 2days not associated with cough ,headache , vomitings.

-h/o alcohol consumption since 15 years.

-k/c/oDM since 10 years on tab.Glimi twice daily.

-N/k/c/o HTN (180/110mmhg@admission) CAD,thyroid ,epilepsy,bronchial asthma.

Examination :

General examination:

-Patient is conscious ,coherent , cooperative.

-No signs of pallor,Icterus,cyanosis,clubbing, lymphadenopathy and edema of feet.

-Temperature,:100°F

-Respiratory rate: 20 cycles/ min

-pulse rate: 108 beats/ min.

-BP: 280/100 mmHg.

Systemic examination:

CVS:

- cardiac sounds: S1S2 +

- no cardiac murmurs.

Respiratory system:

-position of trachea:central

-breath sounds:vesicular 

- no dyspnea ,wheeze.

Abdomen:

-shape of abdomen: scaphoid.

-tenderness: no

-no palpable mass,free fluid.

-liver: palpable.

-spleen: not palpable.

-bowel sounds :yes.

CNS :

Neurological examination:

1).Higher Mental functions:

-consciousness

-orientation to time ,place,person

-speech and language.

-memory : immediate _retentionand recall,recent and remote.

-delusions , hallucinations: no

-emotional liability

-MMSE score:

- orientation: •date,day,month,season,year(5)

•floor,hospital, district,state,country.(5).

-Registration

• name 3 objects taking one second for each object.Ask him to repeat the same 

•repeat till he remembers (3)

Attention and calculation.

•serial7's 5 times.(5)

-Recall.

•recall the three objects(3)

Language.

•name 2 objects (2).

•repeat a sentence (1).

Follow a 3 stage command (3)

•reading 'close your eyes' (1).

•writing a sentence(1)

•copy a design (1)

2).Cranial nerves

3).Reflexes:

                     Right. Left

-biceps. +2 +1

- triceps. +2 +1

-supinator. +1 +1

-ankle. +1 +1

-knee. +2 +1

4).Tone.               

 Upperlimbs. Normal. Hypotonic

 Lower limb. Normal. Hypotonic

5).Power

Upper limbs 4/5 1/5

Lower limbs. 4/5 1/5

DIAGNOSIS:

Left hemiperesis secondary to acute infarct in right MCA territory,mainly fronto parietal operculum, parieto occipital region ,insular cortex.Adjacent corona radiation with k/c/o DM Type 2 since 10 years.

INVESTIGATIONS:

28/5/23

-RBS: 250.

-sr. Na:140

-K+:3.6

-Cl- :105

-Ca+² :1.09.

29/5/23.

-FBD :248

-HbA1c: 6.9

*Hemogram-

-Hb :16.2 gm

-TLC :8800

-platelets: 62000

LFT:

-TB :1.03

-DB: 0.22

-SGOT :27

-SGPT :20

-ALP :111

-Total proteins: 7.3

-Albumin: 3.95

 

-sr.creatinine: 0.7

-sr.Na+ : 143

-K+ :3.5

- Cl- :104

-Ca+2 :1.13

31/5/23.

-Hb : 17 gm

-TC : 11000

-Neutrophils :75

-Lymphocytes :14

-eosinophil :1

-platelet

s:2.35 lakhs.

-MCH :33

-MCHC :34.5

ECG:

*Ultrasound:

MRI:

*Colour Doppler 2D echo

TREATMENT:

-inj.Thiamine 200mg in 100 ml NS IO/BD.

-Tab.Ecosprin.

-Tab.Amlodipine 5mg PO/OD.

-Tab.Ultracet.

-Tab Dolo650 mg PO/sos.

-Tab.Lorazepam.