65 YR OLD MALE CAME WITH CHIEF COMPLAINTS OF GIDDINESS SINCE MORNING , AND RIGHT UPPER LIMB AND LOWER LIMB WEAKNESS SINCE MORNING , DEVIATION OF MOUTH TO THE LEFT SIDE SINCE MORNING.
CBBLE UDHC SIMILAR CASES
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60 YEAR OLD MAN KNOWN HYPERTENSIVE AND DIABETIC SINCE 1 YEAR WITH HISTORY OF CEREBROVASCULAR ACCIDENT 6 MONTHS BACK PRESENTED WITH THE CHIEF COMPLAINTS OF GIDDINESS SINCE MORNING , AND RIGHT UPPER LIMB AND LOWER LIMB WEAKNESS SINCE MORNING , DEVIATION OF MOUTH TO THE LEFT SIDE SINCE MORNING.
PATIENT WORKS AS A CARPENTER AT MIRYALAGUDA AND HAS THREE CHILDREN. ONE YEAR BACK HE WAS DIAGNOSED WITH HYPERTENSION AND TYPE 2 DIABETES MELLITUS ON ROUTINE INVESTIGATIONS AND IS ON IRREGULAR MEDICATION.
6 MONTHS BACK HE EXPERIENCED GIDDINESS WITH SLURRED SPEECH FOR WHICH HE WAS TAKEN TO AN OUTSIDE HOSPITAL AND HIS CT BRAIN REVEALED -
• SMALL HYPODENSE AREAS IN THE BRAINSTEM , BILATERAL CAPSULOGANGLIONIC REGIONS
? OLD VASCULAR INSULT
• BILATERAL PERIVENTRICULAR WHITE MATTER HYPODENSITIES.
? CHRONIC ISCHEMIC CHANGES
• AGE RELATED ATROPHIC CHANGES
HISTORY OF TRAUMA TO HIS RIGHT SHOULDER (HE ACCIDENTALLY WALKED INTO THE WALL) SINCE THEN THE PATIENT HAS BEEN COMPLAINING OF PAIN OF LIFTING HIS RIGHT ARM
PATIENT HASN'T BEEN TAKING HIS ANTIHYPERTENSIVE MEDICATIONS SINCE 2 DAYS .
TODAY MORNING AFTER WAKING UP FROM HIS BED, THE PATIENT EXPERIENCED GIDDINESS AND ON TRYING TO GET UP FROM HIS BED HE FELL FROM HIS BED FOLLOWING WHICH HE DEVELOPED THE SWELLING OF HIS LIPS.
HE ALSO NOTICED RIGHT UPPER LIMB AND LOWER LIMB WEAKNESS.
HIS WIFE AND SON NOTICED DEVIATION OF MOUTH TO THE LEFT AND THE PATIENT DEVELOPED SLURRED SPEECH FEW MINUTES LATER.
ON PRESENTATION TO OUR CASUALTY, THE PATIENT WAS UNABLE TO WALK WITHOUT SUPPORT.
WE INSTANTLY NOTICED SWELLING OF HIS LIPS AND DEVIATION OF HIS MOUTH TO THE LEFT SIDE
THE PATIENT WAS CONSCIOUS, COHERENT, COOPERATIVE WITH A GCS OF 15/15
HOWEVER HE HAD SLURRED SPEECH, WITH INTACT COMPREHENSION AND REPETITION.
HIS BP WAS 160/110MMHG
PR WAS 118 BPM
SPO2 WAS 99 % @ RA
RR WAS 16 CPM
GRBS WAS 154MG/DL
ON NEUROLOGICAL EXAMINATION:
HMF INTACT
SPEECH - SLURRED WITH INTACT COMPREHENSION AND REPETITION
CNS EXAMINATION-
TONE - REDUCED IN RIGHT UPPER LIMB
POWER:
RIGHT LEFT
UPPER LIMB 4+ 5
LOWER LIMB 4+ 5
REFLEXES:
BICEPS 3+ 3+
TRICEPS 3+ 3+
SUPINATOR 3+ 3+
KNEE 3+ 3+
ANKLE 2+ 1+
SENSORY SYSTEM - INTACT
CRANIAL NERVES:
LOSS OF NASOLABIAL FOLD ON THE RIGHT SIDE
DEVIATION OF MOUTH TO THE LEFT SIDE
DROOLING OF SALIVA ON THE RIGHT SIDE
LOSS OF FRONTAL FOLDS ON THE RIGHT SIDE
PATIENT IS ABLE TO PERFORM HEEL TO KNEE TEST
FINGER NOSE TEST
FINGER FINGER TEST
GAIT VIDEO -
https://youtube.com/shorts/6AmYr-6UaVA?feature=share
CVS - S1, S2 PRESENT
LUNGS - CLEAR ON AUSCULTATION
PER ABDOMEN -
NON TENDER
BOWEL SOUNDS +
ON INITIAL EVALUATION WE SUSPECTED AN ACUTE MCA INFARCT ON THE LEFT SIDE
PATIENT WAS SHIFTED FOR THE MRI BRAIN WHICH REVELEAD
IMPRESSION:
✓ Acute infarct in anterior aspect of left thalamus.
✓ Acute lacunar infarct in right lentiform necleus.
✓ Chronic lacunar infarct in left side of pons.
✓ Small vessel ischemic changes in brainstem & supratentorial cerebral hemispheres.
CAROTID DOOPLER :-
IMPRESSION :-
7 x 2 MM ECCENTRIC SOFT PLAQUE NOTED IN LEFT CAROTID BIFURCATION CASUSING NO SIGNIFICANT STENOSIS.
USG ABDOMEN :
NO SONOLOGICAL ABNORMALITY DETECTED.
2D ECHO
Impression:-
EF:- 58%
Concentric LVH , No RWMA
Diastolic dysfunction , No PAH /PE
GAIT VIDEO -
https://youtube.com/shorts/6AmYr-6UaVA?feature=share
ECG
RAPID ANTIGEN NEGATIVE
Chest Xray PA view
XRay Right Shoulder
PROVISIONAL DIAGNOSIS:
ACUTE LEFT LENTIFORM NUCLEUS INFARCT
HISTORY OF CVA 6 MONTHS BACK.
RIGHT LMN FACIAL NERVE PALSY.
KNOWN CASE OF HYPERTENSION AND DM TYPE 2 SINCE 1 YEAR
PLAN OF CARE
HEAD END ELEVATION
1 AMP OPTINEURON IN 100 ML NS IV/OD
TAB ECOSPRIN 75 PO/HS
TAB ATORVAS 20 MG /PO/HS
TAB TELMA 40 MG PO/OD
TAB ZORYL M1 PO/OD
PHYSIOTHERAPY OF RIGHT UL & LL
DAY 2 AMC BED NO : 1
S: Sensorium improved
O:
Pt c/c/c
Temp: Afebrile
PR : 82bpm
SPO2 : 99%
GRBS : 127mg%
BP: 120/80mmhg
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender
A : RIGHT SIDED CVA WITH
ACUTE LEFT LENTIFORM NUCLEUS INFARCT
HISTORY OF CVA 6 MONTHS BACK ,LEFT THALAMUS ANTERIOR ASPECT.
KNOWN CASE OF HYPERTENSION AND DM TYPE 2 SINCE 1 YEAR
PLAN OF CARE
HEAD END ELEVATION
1 AMP OPTINEURON IN 100 ML NS IV/OD
TAB ECOSPRIN 75 PO/OD
TAB ATORVAS 20 MG /PO/HS
TAB TELMA 40 MG PO/OD
TAB ZORYL M1 PO/OD
T.ZORYL M1/PO/OD
STRICT I/O CHARTING
PHYSIOTHERAPY OF RIGHT UL & LL
DAY -3 , AMC BED NO : 1
S : Sensorium improved
O :
Pt c/c/c
Temp: Afebrile
PR : 82bpm
SPO2 : 99%
GRBS : 127mg%
BP: 160/100mmhg
CVS: S1S2 Heard
RS: BAE+
P/A: Soft , non-tender
A: RIGHT SIDED CVA WITH
ACUTE LEFT LENTIFORM NUCLEUS INFARCT . ACUTE INFARCT IN LEFT THALAMUS ANTERIOR ASPECT.
HISTORY OF CVA 6 MONTHS BACK .
KNOWN CASE OF HYPERTENSION AND DM TYPE 2 SINCE 1 YEAR
PLAN OF CARE
HEAD END ELEVATION
1 AMP OPTINEURON IN 100 ML NS IV/OD
TAB ECOSPRIN 75 PO/OD
TAB ATORVAS 20 MG /PO/HS
TAB TELMA 40 MG PO/OD
TAB ZORYL M1 PO/OD
T.ZORYL M1/PO/OD
STRICT I/O CHARTING
PHYSIOTHERAPY OF RIGHT UL & LL
SYRUP CREMAFFIN PLUS 30 ML SOS
