CVA case

 A 70 years old male farmer by occupation presented to the casualty with complaints of weakness of right upper and lower limb with inability to talk since yesterday (8/9/23)

Date of Admission: 08/09/23

CHIEF COMPLAINTS 

Weakness of right upper and lower limb since 5 days.

Inability to talk since 5 days.

HISTORY OF PRESENTING ILLNESS

 Patient was apparently asymptomatic since 5 days back and then speech got slurred while having lunch.He developed marked weakness in right upper and lower limbs. 

 Next day weakness persists and he was not able to talk so they brought to the hospital.

 Weakness was sudden in onset non progressive. No aggravating or relieving factor.

Slurring of speech was sudden and progressed to inability to talk. 

H/o Drooling of saliva 

H/o hiccups 

No h/o deviation of mouth 

No h/o involuntary movements, bladder and bowel incontinence 

No h/o loss of consciousness 

No h/o breathlessness , cough, fever, palpitation, reduced urine output and vomiting. 

HISTORY OF PAST ILLNESS 

Patient had similar complaints 1 year back for which he took medication for 3 months and as symptoms got improved he left the medicine. 

K/c/o CVA (left hemiparesis)  1year back 

K/c/o HTN since 2 years

N/k/c/o Diabetes, epilepsy, TB, Asthma 

DRUG HISTORY 

tablet amlodipine 5mg 

tablet atenolol 50mg po/od

PERSONAL HISTORY

➤Occupation: Farmer

➤Patient is married .

➤Patient takes mixed diet and has a normal appetite.

➤Bowel and bladder movements are normal 

➤No known allergies .

➤Addictions - Consumes alcohol regularly  

General Examination


➤Pallor : not seen 

➤Icterus : not seen 

➤Cyanosis : not seen 

➤Clubbing : not seen 

➤Lymphadenopathy : not seen 

➤Edema : not seen 


VITALS 


➤Temperature : 98.2℉

➤PR : 74 beats per minute

➤BP: 160/90 mm of Hg 

➤RR : 20 cycles per minute

➤SpO2 : 98% in room air

➤Blood Sugar (random) : 269mg/dl

SYSTEMIC EXAMINATION

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent 

➤Speech :  Impaired

➤No signs of meningeal irritation 


Motor system


Tone:-


Rt UL - Hyper

Rt LL-Hyper


Lt LL-Hypo

Lt LL- Hyper

Power:-


Rt UL - 0/5      Lt UL-2/5


Rt LL - 0/5       Lt LL-2/5


Reflexes: 


RIGHT 

Biceps: ++

Triceps: ++

Supinator: ++

Knee: ++

Ankle: ++

Plantar:  Extensor

LEFT

Biceps: +++

Triceps: ++

Supinator: ++

Knee: +++

Ankle: ++

Plantar:  Extensor

Involuntary movements - absent

Fasciculations - absent

sensory text cannot be elicited

Cerebellum - 

Finger nose test , dysdiadochokinesia, Rhomberg test could not elicited.

Autonomic nervous system - normal

• Meningeal sign  

Neck stiffeness -absent 

Brudzinski sign -absent

Kernigs sign - absent


CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent.,

➤No cardiac murmurs


RESPIRATORY SYSTEM

➤Normal vesicular breath sounds heard.

➤Bilateral air entry present

➤Trachea is in midline.

ABDOMINAL EXAMINATION

INSPECTION

➤Shape - Scaphoid

➤Equal movements in all the quadrants.

➤No visible pulsation, dilated veins and localized swellings.

PALPATION

➤Liver , spleen not palpable.

➤No tenderness 


PROVISIONAL DIAGNOSIS : RIGHT HEMIPARESIS 

 RECURRENT CVA WITH K/C/O HYPERTENSION SiNCE 2 YEARS 


INVESTIGATIONS : 

 

1. Haemogram

                            9/09/23             10/09/23

 Hb ;                    13.4                    13.3

TLC :                  11,000                 14,300

Platelet count :     3.18                     3.1

PCV :                    38.4                    38.3


3. Serum Creatinine  - 1.3


4. Serum Na+ - 131


5. Serum Chloride - 98


6. Serum Calcium - 1.14


7. Blood urea - 41


8. RBS - 210 

TREATMENT


1) Ryle's tube feeding - 2nd hourly water and 4th hourly milk

2) Ecosporin - AV 75 mg/hr PO OD

3) Atenolol 50mg

4)Physiotherapy 


Comments

Post a Comment

Popular posts from this blog

Image
GENERAL MEDICINE CASE PRESENTATION    A 70 yr old male agriculture by occupation was brought to causality in an unconscious state since yesterday. CHIEF COMPLAINT:  Fever since 3 days  Abdominal pain since 3 days HISTORY OF PRESENT ILLNESS: *  Patient was apparently asymptomatic 1 week back after which he started Binge drinking for 2 days. *He developed Fever that last for 3 days and developed Abdominal pain Burning type both for which he was treated by local Doctor. * After that he developed weakness which is gradual in onset and was unable to stand for which he was admitted to local hospital where he was diagnosed to have DENGUE FEVER (through NS1 ANTIGEN Positive) and the Platelet Count was 24,000.  PAST HISTORY: *Patient is a known case of Chronic Alcoholism since 30 years and increased his intensity since last 3 years.  *smoking since 20 yrs, average 2  beedi per day TREATMENT HISTORY: * No Past history of treatment  PERSONAL HISTORY: * He is a chronic alcoholic since 30 years  *
Read more
Image
  AKI 2° to Rt nephrectomy  Case scenario:- PT aged 40 yrs F Farmer by occupation came to opd with c/o of Vomitings since 15 days nausea since 15 days Pt was apparently normal 4yrs back then she had burning micturition pedal edema and rt loin pain and diagnosed with renal calculi(2 to 3 cm) Pt has right kidney nephrectomy in 2018 HISTORY OF PRESENT  ILLNESS Since 10 to 15 days pt had nausea and Vomiting  HISTORY OF PAST ILLNESS Right kidney nephrectomy in 2018 N/k/c/o BP and HTN PERSONAL HISTORY  Mixed diet Married Farmer by occupation  PHYSICAL EXAMINATION  Patient is conscious, coherent and cooperative •Moderately built and Moderately nourished •No signs of - Pallor                        Cyanosis                        Clubbing                        Icterus VITALS • Temp - 98.4F •Pulse rate - 82 BPM •RP - 16 /min •BP - 130/70 mm hg •SPO2 - 98 SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM • S1, S2 heard • No murmurs RESPIRATORY SYSTEM:   •Position of trachea - central •Breath sounds -
Read more