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Hall ticket number :1801006002
This is a case of 55 year old gentleman farmer by occupation resident of Yadagirigutta came to OPD on 13 March 2023 with
CHIEF COMPLAINTS
Slurring of speech since 2 days
Deviation of mouth towards left side since 2 days
HISTORY OF PRESENTING ILLNESS
patient was apparently asympotomatic 2 days ago then he developed slurring of speech which is sudden in onset and
His wife noticed deviation of mouth to left side and took him to local doctor for which he was given ORS but symptoms had not subsided ,the next day his wife took him to another doctor where He was told to take rest
On monday morning he was brought to our hospital at the time of presentation slurring of speech decreased and slight deviation of mouth was present
He also had blurring of vision for an hour on 11 March 2023
No weakness of upper and lower limb.
No h/o involuntary movements
No h/o of numbness or paresthesia
No loss of consciousness
No drooling of saliva
No drooping of eyelids
No difficulty in swallowing
DAILY ROUTINE
He wakes up at 5 AM performs his daily routine,and prays for an hour , eats breakfast by 8AM usually rice and goes to fields by 9 AM on TVS scooter along with his wife ,takes lunch along with him and eats lunch by 1 pm and comes back home at 6 PM and takes bath, drinks tea and eats dinner by 8 PM , he usually eats rice prays for an hour and goes to bed
PAST HISTORY
No history of similar complaints in the past
He is a known case of Hypertension since 1 year and does not take his medications regularly
History of tuberculosis 21 years ago ,took medications for 6 months
History of perforation to tympanic membrane 21 years back for which he is using a hearing aid
No history of diabetes, asthma ,epilepsy
PERSONAL HISTORY
Diet : mixed
Appetite : normal
Sleep: usually sleeps for 5-6hours
Bowel and bladder : regular
Addictions : he used to drink Sara since he was 23 years but stopped at 30 years of age
FAMILY HISTORY
Father : known case of DM ,Hypertension ,Tuberculosis
Mother died due to breast cancer
Both the sons of the patient were also affected with tuberculosis along with him
Both his sisters are known case of diabetes and Hypertension
Brother , sister in law,Both their children were affected with tuberculosis
Brother had history of stoke 3 years back
GENERAL PHYSICAL EXAMINATION
Patient is conscious, coherent,cooperative. Moderatly built and Moderately nourished
No pallor ,icterus, cyanosis, clubbing, lymphadenopathy, pedal edema
VITALS
Temperature : afebrile
Pulse rate : 70 bpm
Blood pressure :130/80 mmHg
Respiratory rate : 18 cycles per minute
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM EXAMINATION
1.HIGHER MENTAL FUNCTIONS
Conscious, coherent, cooperative
- oriented to time, place, person
- Memory intact
- Speech - comprehension present, fluency, repetition present
2. CRANIAL NERVE EXAMINATION
- I- Olfactory nerve- sense of smell present
- II- Optic nerve- direct and indirect light reflex present
- III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis
- V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.
- VII- Facial nerve- face is symmetrical, forehead wrinkling present, nasolabial folds are prominent on both sides
- VIII- Vestibulocochlear nerve - decreased hearing on left side [rinnes negative for 256 and 512 Hz] and normal hearing on right side
- IX- Glossopharyngeal nerve.
- X- Vagus
- XI- Accessory nerve- sternocleidomastoid contraction
- XII -hypoglossal nerve - deviation of tongue to right side,no fasciculations
Tongue Deviation towards right side
3. MOTOR SYSTEM EXAMINATION
BULK:
Right Left
U/L-
arm 28cm 27cm
forearm 27 cm 26cm
L/L
thigh 49cm 49cm
leg 33cm 31cm
TONE:
U/L normal normal
L/L Normal normal
POWER:
Right Left
U/L-
hand 5/5 5/5
elbow 5/5 5/5
shoulder 5/5 5/5
L/L-
hip 5/5 5/5
knee 5/5 5/5
ankle 5/5 5/5
REFLEXES:
Right Left
Biceps ++ ++
Triceps ++ ++
Supinator ++ ++
Knee ++ ++
Ankle ++ ++
Plantar Flexion Flexion
TRICEPS REFLEX RIGHT ARM
https://youtube.com/shorts/wTMfw5cVjDA?feature=share
TRICEPS REFLEX LEFT ARM
https://youtube.com/shorts/wTMfw5cVjDA?feature=share
BICEPS REFLEX
https://youtu.be/-dO19ZdfvUI
KNEE REFLEX
https://youtu.be/cKTk7LNSmqM
4.SENSORY SYSTEM EXAMINATION
SPINOTHALAMIC SENSATION [on both sides]
Crude touch normal
Pain normal
Temperature normal
DORSAL COLUMN SENSATION[ on both sides]
Fine touch normal
Proprioception normal
CORTICAL SENSATION [on both sides]
Two point discrimination able to discriminate
Tactile localization able to localize
No cerebellar signs
No Meningeal signs
CARDIOVASCULAR SYSTEM:
Inspection :
Shape of chest- elliptical shaped chest
No engorged veins, scars, visible pulsations
No JVP
Palpation :
Apex beat can be palpable in 5th inter costal space medial to mid clavicular line
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs
PER ABDOMEN:
Inspection -
Umbilicus - inverted
All quadrants moving equally with respiration
No scars, sinuses and engorged veins , visible. pulsations.
Hernial orifices- free.
Palpation -
soft, non-tender
no palpable spleen and liver
Percussion:Resonant
Auscultation- normal bowel sounds heard
RESPIRATORY SYSTEM:
Inspection:
Shape of the chest : elliptical
B/L symmetrical ,
Both sides moving equally with respiration
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Auscultation:
B/L air entry present . Normal vesicular breath sounds
Provisional diagnosis:
Acute Cerebrovascular accident
With acute infarct in left internal capsule [small infarct]
INVESTIGATIONS
Complete blood picture
Haemoglobin:11.7
Peripheral smear: normocytic normochromic anemia
Red blood cells:3.86
Pcv:34.6
Platelet count:2.10
Total leucocyte count:5,100
Fasting blood sugar : 92 mg/dl
Serum creatinine :1.3 mg/dl
Blood urea 38 mg/dl
Complete urine examination
Colour : pale yellow
Appearance : clear
Reaction :acidic
Albumin:nil
Sugar: nil
Bile salts and bile pigments : nil
RBC : nil
Crystals :nil
Casts : nil
pus cells:2-3
epithelial cells-2-3
Serum electrolytes
Sodium: 145 mEq/L
Potassium:4.2mEq/L
Chloride:104 mEq/L
Calcium ionized:1.11 mmol/L
ECG
Rate :60 bpm,regular
Sinus bradycardia is present
MRI
Ophthalmology consultation
ECHO
Diagnosis:
Acute Cerebrovascular accident
With acute infarct in left internal capsule and
With acute infarct in occipital lobe
DRUGS:
Treatment:
NS IV OD
TAB. CLOPITAB 75 MG PO/OD
TAB. ECOSPRIN AV 75/10 P
INSTRUMENTS USED
Stethoscope
Torch
Tuning forks
Knee hammer
Measuring tape
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