Long case

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A 55 Yr old female ,housewife, resident of Guntur (macharla) informant being daughter presented with chief complaints of 

-Weakness of Upper limb since 1 day (afternoon)

-Weakness of right Lower limb  since 1 day

-Inability to speak since night

-Confusion at the time of admission 

HOPI:

Patient was apparently normal 2 days back later on, primarily she developed giddiness in the morning which later resolved on next day by medication prescribed by RMP (CINARIZINE)

On examination by RMP ,he also found that  her sBP  was around 280 mmhg and gave antihypertensive (TELMISARTAN)

On the next day,while she was going to washroom she was unable to lift her right hand and move her right leg ,unable to do her daily routine 

She was dragging her leg which was noticed by her daughter and later on was laid down to bed and at the night she was unable to lift herself up to use the washroom ,so she was brought to hospital

On the way to hospital, she was unable to recognize her daughter's and unable to speak .

Past  history:

For Diabetes -T. Dapaglifozin 10mg,    T. Metformin 500mg

For Hypertension :T.Telma 40 mg T.Cilindipine 10mg  T.Metoprolol 50mg

Personal History: Diet Mixed 

                                Appetite normal

                               Bowel And Bladder 

                               Sleep Adequate 

                                No Allergies And Addictions.

Family History : not Significant      

General Examination: 

Patient is Conscious, but not Cooperative and is oriented to Place and Person.

Moderately Built and Nourished.

No signs of Pallor,Icterus ,Clubbing, Cyanosis,Lymphadenopathy 

Vitals : 

Temp - 100.8F

PR- 90 bpm

B.P -180/80mmHg

SpO2 94%.

SYSTEMIC EXAMINATION : 

CVS : S1 S2 heard, no murmurs

RS : Bilateral air entry present, normal vesicular breath sounds, no added sounds

GIT : Soft, non-tender, no organomegaly

Higher Mental Functions

Right handed individual

Patient level of consciousness -E4 V1 M4

Higher mental functions are intact

Speech - Markedly reduced , Not assessable 

Signs of meningeal irritation ( neck stiffness,kernigs sign )are absent

Cranial nerves - 

Cranial nerve examination 

I(OLFACTORY) - couldn't be elicited

II(OPHTHALMIC) - Direct and indirect light reflex present

 III,IV,VI(OCCULOMOTOR,TROCHLEAR, ABDUCENS)  - no ptosis Or nystagmus

 V(TRIGEMINAL) - corneal reflex present ( slightly delayed on right side, normal on left side) 

 VII(FACIAL) - no deviation of mouth, no loss of nasolabial folds, forehead wrinkling present

  VIII(VESTIBULOCOCHLEAR) - able to hear

  IX, X(GLOSSOPHARYNGEAL,VAGUS) - position of uvula couldn't be visualized

  XI(ACCESSORY) - sternocleidomastoid contraction present

  XII(HYPOGLOSSAL) - no tongue deviation

MOTOR SYSTEM

Bulk -      R               L

 Arm      26cm          26cm

Forearm 19cm        19cm

Thigh      42 cm           42cm

Leg         28cm             28cm

Upper limb.          R.          L

TONE        Hypotonic      N

 POWER

       DELTOID.        2+.      4+

       BICEPS.          2+.      5+

       TRICEPS.        2+.      5+

       Lumbricals.    2+.      5+

REFLEXES 

                 B               +.     ++

                 T.              +.      ++

                 S.              +.      ++

lower limbs.                       R.            L

TONE.                         Hypotonic.   Normal

POWER

EXTENSORS OF HIP.       2+.          2+

FLEXORS OF KNEE          2+.          2+

EXTENSORS OF KNEE.   2+.          2+

PLANTAR FLEXION         2+.          2+

DORSI FLEXION.              2+.           2+

REFLEXES

             CORNEAL             present.  Present

             CONJUNCTIVAL present.   Present

             KNEE JERK.          +              2+

            ANKLE JERK         +               2+

  (ankle clonus -ve)

            PLANTAR.          Extensor   Flexor

SENSORY SYSTEM.    - rt                              lt

                            Not Responding       responding 

Cerebellar signs : couldn't be elicited

https://youtu.be/4Kt0oB8OD9A

https://youtu.be/uyI54oIBzPc

https://youtu.be/Ux3fexLu4gQ

https://youtube.com/shorts/CShEstMbgco?feature=share

https://youtube.com/shorts/SV66q3zOahc?feature=share

https://youtube.com/shorts/BkZ7HZyue5A?feature=share

 

Investigations:

MRI

T2  weighted image

FLAIR

ADC

DWI

Provisional diagnosis :

Neurological deficit :  MIXEDSENSORYMOTOR system  involved of one side - Hemiparesis

Of right upper and lower limb and Brocas aphasia .

Anatomical - Left Middle cerebral artery territories involved

Etiology : Hypertension and Diabetes Mellitus 

Treatment:- 

-IV FLUIDS-NS @ 75 ml / hr

-RT. 100ml MILK  WITH PROTEIN POWDER 8th hrly

 100ml water Every 2nd hrly

-ING.CITICHOLINE800mg /IV/IN 100 ml NS/BD

-ING.PIRACETAM 800mgIV/IN 100ml NS/TID

-ING.PAN40mg/PO/OD

-TAB. ECOSPIRIN 150mg /PO/HS

-TAB.ATORVAS40mg/PO/OD

-TAB.AMLONG 5mg /PO/OD

-ING .HUMAN ACTRAPID INSULIN ACC. TO GRBS CHECK

-TAB . DOLO 650mg SOS if temp>100F

-B.P. MONITORING 4th hrly