50 year old male with weakness in left upper and lower limb
50 year old male with weakness in left upper and lower limb
June 02, 2023
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A 50yrs old who is a resident of cheruvugattu came with c/o weakness in left UL and LL since today morning(05/05/23)At 8:00AM
HOPI-
patient was apparently asymptomatic till today morning and attenders noticed that he couldn't get up from bed and complained of weakness in left UL and LL which is of sudden onset and gardually progressive.
-No h/o loss of consciousness, involuntary movements, drooling of saliva, involuntary micturation and defeacation.
Daily routine- patient wakes up at 6:00Am in the morning and freshens up and to heis sister in law for breakfast and tea and returns home ,watches Tv and have lunch at 12:30PM and sleep in the afternoon and have tea at5:00 Pm and have dinner at 8:00pm.
Past history-
K/C/O Acute CVA (Rt.hemiparesis) 2yrs back.
-1yr back came to OPD with c/o urinary incontinence ,drooling of saliva.
Took medication and left.
K/C/O HTN and DM since 2yrs and on regular medication.
T.metformin 500mg + glimperide 1mg Po/od (mrng)
T.Amlong 2.5mg po/od
PERSONAL HISTORY:
Diet- mixed
Appetite - normal
Sleep -normal
Bowel and bladder -regular
Addictions-
-He is chronic alcoholic since 30 years, stopped 2 years after right hemiplegia.
-he chews tobacco since 10 years .
FAMILY HISTORY:
No similar complaints in the family.
TREATMENT HISTORY:
He is on antihypertensives and metformin
GENERAL EXAMINATION:-
GCS -E4V4M5
-B/L pupils-NSRL
Pallor - absent
Icterus - absent
Cyanosis - absent
Clubbing - absent
Lymphadenopathy - absent
Oedema - absent
Vitals :-
Temp - 97.2F
BP - 110/70 mm Hg
Pulse rate - 72 bpm
Respiratory rate - 14 cycles per minute
SYSTEMIC EXAMINATION:
CNS EXAMINATION :-
Motor system
Power:-
Rt UL - 3/5 Lt UL-0/5
Rt LL - 3/5 Lt LL-0/5
Tone:-
Rt UL - Hyper
Lt LL-Hypo
Rt LL-Hyper
Lt LL- Hypo
Reflexes:
Right Left
Biceps: ++ +++
Triceps: ++ +++
Supinator: +++ ++
Knee: +++ ++
Ankle: + +
Plantar: flexor. Extensor
Involuntary movements - absent
Fasciculations - absent
Sensory system -
-Pain, temperature, crude touch, pressure sensations,Fine touch, vibration, proprioception -normal
Cerebellum -
Finger nose test , dysdiadochokinesia, Rhomberg test could not elicited.
Autonomic nervous system - normal
• Meningeal sign
Neck stiffeness -present
Brudzinski sign -present
Kernigs sign -present.
ABDOMEN EXAMINATION:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible
pulsations.
CVS EXAMINATION
S1S2 heard,no murmurs.
Respiratory system examination
Bilateral air entry present.
Investigations-
ECG
2D echo
Mild TR with PAH;Mild AR;No MR
No RWMA No AS/MS,sclerotic AV
Good LV systolic function
Diastolic dysfunction ,no PE.
Review 2d echo
Doppler impression-
Raised CIMT in b/l CCA's
b/l CCA and ICA show normal biphasic wave pattern,calibre and colour uptake
No e/o plaques in b/l CCA'S and ICA'S.
Lumbar puncture done on 06/05/23 at 8:30pm
Diagnosis-
Left hemiplegia sec to Acute infarct in right superior parietal lobule;Superior frontal gyrus
K/c/o Right hemiparesis in 2020.
K/c/o HTN and Type 2 DM since 2yrs.
Treatment
1.RT Feeds
-50ml water every 2nd hrly
-200ml Milk+ 2spoons protein powder every 4th hrly.
2.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.
3.inj.optineuron 1amp in 100ml NS IV/OD.
4.T.Ecospirin-AV 75/10
RT/OD.
5.T.Amlong 5mg RT/OD.
6.Monitor BP,PR,RR,Spo2,Temp
7.GRBS 7 profile
8.physiotheraphy
9.Frequent position change 2nd hrly.
Follow up -06/05/23
GCS-E4V3M5
Vitals :-
Temp - 97.2F
BP - 130/80 mm Hg
Pulse rate - 90bpm
Respiratory rate - 20 cycles per minute
Motor system
Power:-
Rt UL - 3/5 Lt UL-0/5
Rt LL - 3/5 Lt LL-0/5
Tone:-
Rt UL - Hyper
Lt LL-Hypo
Rt LL-Hyper
Lt LL- Hypo
Reflexes:
Right Left
Biceps: ++ +++
Triceps: ++ +++
Supinator: +++ ++
Knee: +++ ++
Ankle: + +
Plantar: flexor. Extensor
07/05/23-
GCS-E3V3M5
S + +
K ++ ++
A + +
P Flexor Extensor
Tone:
Rt Lt
UL. Hyper hyper
Hyper hyper
Power:
Rt. Lt
UL. 3/5. 2/5
L L 0/5. 0/5
A:
Left hemiplegia sec to Acute infarct in right superior parietal lobule;Superior frontal gyrus
K/c/o Right hemiparesis in 2020.
K/c/o HTN and Type 2 DM since 2yrs.
-stool not passed
P:
1.RT Feeds
-100ml water every 2nd hrly
-200ml Milk+ 2spoons protein powder every 4th hrly.
2.Inj.Piptaz 4.5gm IV TID
3.Inj.Clindamycin 600 mg IV TID
4.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.
5.inj.optineuron 1amp in 100ml NS IV/OD.
6.T.Ecospirin-AV 75/10
RT/OD.
7.T.Amlong 5mg RT/OD.
8.Monitor BP,PR,RR,Spo2,Temp
9.GRBS 7 profile
10.IVF - 2NS @75ml/hr
10.physiotheraphy
11.nebulisation - ipravent 2nd hrly,mucomist 2nd hrly,budecort-4th hrly.
12.Frequent position change 2nd .hrly
13.syp.LACTULOSE 15ml/RT/HS.