A 65 year old male with right upper and lower limb weakness

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CASE DISCUSSION:

A 65 years old male came to the OPD with

chief complaints of difficulty in lifting right upper limb and lower limb since 3days.

Deviation of angle of mouth towards right since 3days.

Difficulty in swallowing liquids and solids since 3 days.

History of presenting illness:

Patient was apparently asymptomatic 7 years ago then he had dinner around 8pm and slept, at 2pm he woke up to pass urine then he suddenly fell in the bathroom following which he had right side hemiparesis for which he went to a private hospital and was diagnosed with CVA and HYPERTENSION, given medication and discharged.

The patient took ?medications for 1year and stopped taking them, took physiotherapy for 1 month it took 3months to walk but did not recover completely and since then uses cane to walk.

The patient was started on ANTI HYPERTENSIVES ? which he used for one year.

No slurring of speech during this episode.

No loss of consciousness.

Later he took his medications on and off till 1 year ago since then he completed stopped taking medication.

On 6/02/2022,

Patient went to use washroom around 5am and was not able to get up after passing urine.

Slurring of speech was present,Deviation of angle of mouth towards right, 

Dysphagia, right side hemiparesis.

He was taken to a private hospital and was admitted there for three days, took a CT BRAIN impression:

Ill-defined patchy hypodensity in left body of caudate nucleus and left corona radiata - ?subacute to chronic infarct. 

Chronic lacunar infarcts in bilateral capusloganglionic regions and bilateral corona radiata.

Diffuse cerebral atrophy.

Chronic small vessel ischemic changes.

Then was referred here for further treatment.

Past history

Not a k/c/o DM, TB, Asthma, Epilepsy.

Personal history of

DAILY ROUTINE before illness:

5am- wakes up and get ready

7am- Tea

10am- breakfast

12pm- goes to work (goatherd)

6pm- come back home and cleans up

8pm- dinner

9pm- sleeps

after illness: patient has the same routine as before, but has difficulty in walking.

Diet- Mixed

Appetite- Normal

Bowel- regular, passed stools 3 days ago ; bladder movements- Regular.

Sleep- Adequate

Addictions- H/o alcohol consumption 90ml/day for 20years 7 years ago ,since then consumes occasionally.

Surgical history- Cataract surgery in both eyes 8 years ago

Family history:

Insignificant

General examination:

The patient was examined in a well-lit room after informed consent was taken.

He is conscious, coherent, cooperative, well oriented to time, place and person. He was well nourished and moderately built.

No Pallor, Icterus, Clubbing, Cyanosis, Koilonychia, Lymphadenopathy, Edema.

Vitals:

PR: 92bpm

RR: 22cpm

BP: 110/90 mmHg

Temperature: 99°F

GRBS: 94mgdL

SpO2: 95% on room air.

Systemic examination:

CNS

HIGHER MENTAL FUNCTIONS:

Oriented to time,place,person

Memory : immediate,recent, remote intact

Speech: slurred

No delusions or hallucinations

CRANIAL NERVES: 

1- not tested

2- counting fingers+

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

 7-deviation of Angle of mouth to right side.

8- Normal hearing

9,10-difficulty in swallowing and slurred speech, gag reflex not tested

11,12- normal.

MOTOR EXAMINATION:

TONE: Increased in right upper and lower limbs and normal in left upper and lower limbs 

POWER :   Right        Left

Upper limb 4/5              4/5

Lower limb 3/5              4/5

Reflexes : Right                 Left

Biceps:       3+                      2+

Triceps:      3+                      2+

Supinator   3+                     2+

Knee:          2+                      2+

Ankle:          -                         -

Right biceps

SENSORY EXAMINATION: 

Pain and touch present

CEREBELLUM EXAMINATION:

Able to do finger nose test.

dysdiadokinesia present

No rebound tenderness 

Gait: couldn't walk , CIRCUMDUCTION PATTERN (as patient's attenders described)

AUTONOMIC NERVOUS SYSTEM:

No abnormal sweating

No resting tachycardia

MENINGEAL SIGNS: Absent

 

CVS: S1 and S2 heard.

RS: BAE+ NVBS+

Per abdomen

Soft, non tender, no distension, umbilicus is central and inverted,no scars, no sinuses.

INVESTIGATIONS:

HEMOGRAM 

Hb- 15.4g%

TLC- 8,700 cells/cc

Neutrophils-78

Lymphocytes- 12

Eosinophils-2

Monocytes-8

Basophils-0

PCV-43.7

MCV- 37.8

MCH-30.9

MCHC-35.2

RDW-CV- 13

RDW-SD- 42.5

RBC- 4.98m/cc

Platelets- 2.18lakh

PS- NORMOCYTIC NORMOCHROMIC

LFT

TB- 2.11

DB- 0.94

AST- 41

ALT- 26

ALP- 98

TP- 7.4

ALB- 3.83

A/G- 1.07

RFT

Serum urea- 22

Serum creatinine- 1.1

Na+: 135

K+: 4.1

Cl- 98

SEROLOGY

HIV- NEGATIVE

HBsAg- NEGATIVE

HCV- NEGATIVE

ECG

COLOUR DOPPLER 2D ECHO

PROVISIONAL DIAGNOSIS:

 Subacute ischemic CVA stroke 

TREATMENT:

Tab. CLOPITAB 75mg PO/OD

Tab. ECOSPRIN 75mg PO/OD

Tab. ATORVA 20mg PO/OD

RT feeds 4th hourly 100ml milk and 200ml water

BP/PR/RR/ Temp. Charting 4th hourly

Tab. PAN 40mg PO/OD

Inj. OPTINEURON 1amp in 500ml NS/IV/OD

 

Right side supinator and brachioradialis

Left knee

Right knee