A 78 year old male came to casualty with weakness of right upper limb and lower limb since 4 days

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A 78 year old male came to casualty with 

CHIEF COMPLAINTS -

c/o weakness of right upper limb and lower limb since 4 days.

C/o inability to talk since 4 days 

HOPI- 

patient was apparently asymptomatic 2 years back then he developed weakness of left upper limb and lower limb, sudden in onset, non- progressive, it was associated with slurring of speech, he went to a local hospital in Nalgonda and was treated conservatively , recovered within 5 days.

H/o weakness in the right upper limb and lower limb since 4 days, sudden in onset, non- progressive, no aggrevatin and relieving factors.

H/o inability to talk since 4 days, sudden in onset, non- progressive.

H/o hiccups since yesterday, continuous.

No H/o deviation of mouth.

No H/o involuntary movements, bowel and bladder incontinence

No H/o fever, burning micturition , vomiting 

PAST HISTORY-

K/C/O CVA [ LEFT HEMIPARESIS ] 2 years back 

K/C/O HTN since 2 years and is on tab. Amlong 5mg, tab. Atenolol 50 mg PO/OD.

NOT A K/C/O  DM, epilepsy, asthma,TB, thyroid disorders.

PERSONAL HISTORY- 

Diet- mixed 

Appetite- decreased 

Sleep- adequate 

Bowel and bladder movements- regular 

No allergies 

Addictions- consumes alcohol or toddy occasionally 

FAMILY HISTORY- not significant 

GENERAL EXAMINATION-

patient is conscious, coherent, cooperative. Well oriented to time , place and person, moderately built and moderately nourished 

Vitals -

BP- 170/100 mmHg

PR- 80 bpm

RR- 16cpm

TEMP- 96.8 F

NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, OEDEMA.

SYSTEMIC EXAMINATION-

1) CNS:

Higher mental functions - intact

Cranial nerves - intact

Motor examination:      R               L

 

Bulk.                              N               N

Tone.        UL               Hypo        Hypo 

                  LL              Hyper       Hyper

Power.       UL               0/5              3/5    

                   LL.              0/5              2/5

        

Reflexes:

Biceps.                         3+              3+

Triceps.                        3+              2+

Supinator                     2+             2+

Knee                             3+              3+

Ankle.                           3+             2+

Plantar.                     Extensor.  Extensor

Sensory examination:Normal

No meningeal signs

2) CVS- S1, S2 heard, no murmurs.

3) RS- BAE present, NVBS 

4) PER ABDOMEN- soft , non tender, no organomegaly

PROVISIONAL DIAGNOSIS-

right hemiparesis with acute infarct in left superior frontal lobe ( left ACA territory )

With K/C/O left hemiparesis since 2 years.

K/C/O HTN since 2 years.

INVESTIGATIONS-

Hemogram-

On 9/9/23-

Hb - 13.4

TLC - 11000

Plt count- 3.18

PCV- 38.4

On 10/9/23

Hb- 13.3

TLC-14,300

Plt count- 3.1

PCV- 38.3

On 11/9/23

Hb- 13.4

TLC - 14,300

PCV- 39.6

Plt count- 3.21

9/9/23

Serum creatinine- 1.3

Serum Na+  131

Serum K+   3.2

Cl-  98

Blood urea- 41

RBS- 210

10/9/23

Urinary chloride- 189

Spot urinary K+  25

Spot urinary Na+  140

FBS - 259

 

CUE- 

ECG-