adarshini e log

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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

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CASE DISCUSSION:

A 50yr old male Patient from charuvugattu was brought by his attenders(daughter and his brother) to  the hospital  with complaints of loss of speech since 5 days, right upper limb weakness since 2 days and deviation of mouth to left side since 2 days. 

  HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic 5 days back and then developed loss of speech which was sudden in onset and progressive in nature. No h/o loss of comprehension. 

          Right upper limb weakness since 2 days which was sudden in onset and progressive in nature. Not associated with tingling and numbness. No h/o weakness in opposite limb. 

        Deviation of mouth to left side since 2 days which is associated with drooling of saliva fromm right angle of mouth. 

h/o loss of nasolabial fold on right side. 

h/o difficulty in drinking water. 

NO H/O: 

          *Difficulty in standing from sitting                position. 

          *Difficulty in climbing stairs and                    wearing chappals. 

          *Numbness, tingling. 

          *Nausea, vomiting, diarhhoea

          *sensory deficit in feeling clothing. 

          *Involuntary movements

          * wasting/thinning

          *Band like sensation

          * low back ache

          *cotton wool sensation

          *postural giddiness, palpitation

          * seizures

          *Head trauma/ loss of memory

          *loss of perception of smell

          *Blurring of vision/ double vision

          * loss of sensation over face

          *Difficulty in chewing food

          * Abnormality in taste sensation

          * loss of hearing and giddiness. 

          *Difficulty in swallowing food

          * Regurgitation of food. 

          *Difficulty of shrugging shoulder 

          * Tongue deviation

          *Difficulty in making food bolus

          *Tremors/ Tongue fasciculations. 

          * Fever, vomitings and neck                            stiffness. 

PAST HISTORY:patient had alleged h/o RTA (fall from bike) 7yrs back and had fracture of right medial malleolus for which he underwent open reduction and internal fixation. 

not a k/c/o HTN,DM,CVA,CAD,SEIZURES, ASTHMA, TB. 

PERSONAL HISTORY:His appetite was normal and takes mixed diet, sleep adequate, bowel and bladder movements were regular. Chronic alcoholic( 90ml per day)and tobacco chewer since 30 yrs .

General examination:pt.is conscious, coherent, co-operative ,oriented ,moderately built and poorly nourished. Comfortable . 

        Pallor - Negative

        Icterus- negative

        No cyanosis ,clubbing                                          lymphademopathy,pedal                               edema.

Skin shows both asymptomatic hypo and hyper pigmented scaly plaques over both upper limbs , trunk and back since 10 yrs. For which dermatology opinion was taken. 

 VITALS:

    Bp: 140/90 mmhg

    Pr :80bpm

    spo2 :98%at room air

    temp :97°F

    RR -18cpm

    Grbs -136gm/dl

   Cvs -s1 s2 heard,no murmurs

   Rs -bae +,nvbs heard

   P/a soft ,nontender,bowels sound heard,

CNS:

    HMF- patient conscious, orientation is not elicited

        Speech- motor aphasia(+) . 

        No h/o delusions, hallucinations. 

              h/o emotion lability. 

cranial nerves:   Right               left

1 st: smell             (+)                 (+) 

2nd  :VA/color       (+)                 (+) 

              Vision

                                             

3rd,4th,6th:

                 pupil size.      N         N

                 DLR/CLR.       N.        N

                 NO pstosis, nystagmus.

5th :

  sensory:over face and buccal mucosa                     normal

  motor :mastication movements -                             normal. 

  reflex :corneal andconjuctival -(+) 

              Jaw jerk (-). 

7th:

 motor: 

     Nasolabial        (-)              (+) more

       Fold                                   prominent. 

     Facial mov.    Weakened     Normal 

 sensory: ant. 2/3 rd of tongue -Normal. 

 secretomotor: moistness of eye and                                   tongue normal,buccal                                   mucosa normal. 

8 the nerve:

       Rinnes : AC>BC

       Weber's:Not deviated to any side I. e, 

                       Central. 

        No nystagmus. 

9and 10 th nerve: 

             uvula centrally placed and symmetrical,gag  and palatal reflex (-). 

11 th nerve: 

   trapezieus :          N                         N

 sternocleidomastoid :N                   N

12 th nerve: 

         tongue tone normal, no wasting, no           fibrillations,no deviation of tongue. 

MOTOR SYSTEM 

                         Right.             Left

Bulk:               Normal.        Normal

Tone: u/l.        Normal          Normal

           L/L.       Normal          Normal

Power:u/l         4/5                 5/5

             l/l          5/5                 5/5

Reflexes.  

   Superficial reflexes:

                       Right.           Left

Corneal-            (+)              (+) 

Conjunctival-    (+)              (+)            

Abdominal-       (-)                (-) 

Plantar-        Decreased     Decreased

    Deep tendon reflexes :

                     Right.            Left

Biceps.          +++             +  

Triceps.         ++                 +  

Supinator.     +++               +  

Knee              ++                 ++     

Ankle.            +                    +

 

SENSORY SYSTEM: 

          Not elicited due to motor aphasia. 

CEREBELLUM

titubation - absent

Nystagmus- absent

Intensional tremors - absent

Hypotonia-no

Pendular knee jerk 

Dysdiadokinesia

MENINGIAL SIGNS

Neck stiffness - negative

Kernigns sign - negative

Brudzinkis sign - negative

INVESTIGATIONS: on25/7/2020.

     *HEMOGRAM : 

                

HB :   15.4 gm/dl.    

Platelets : 2.2 lakh/mm3

TLC :7, 400/mm3

RBC: 5.3million/mm3.                                           

      *LFT:

TOT.BIL. :    1.21         

DI.BIL.   :       0.34        

SGOT. / AST:   10               

SGPT.  /ALT :    12      

ALK.PH.  :         108   

Tot. Prot. :         5.4                    

ALB.  :                  3.7                                  

A/G RATIO.:       2.29                                  

       *RFT

UREA.  :      23          

CREATININE. :   0.9    

URIC ACID :   5.6                                    

CALCIUM.:      10.1                                    

PHOS. :            3.4                                 

SODIUM :        136                                   

K+:               4.1                                     

CL- :              9.7   

       *RBS:   101 Mg/dl.

       *LIPID PROFILE-

    Total cholesterol: 177

    Triglycerides:180

     HDL:95

     LDL:108

     VLDL:36

      *MRI.

      

 DIAGNOSIS: Acute infarct in left frontal lobe with pityriasis versicolor. 

                                     

 

TREATMENT 

1) TAB. Ecospirin 75mg/od/po

2) TAB. clopidegral 75 mg/od/po

3) TAB. Atorvastatin 40 mg/od

4) TAB. B-PLEX FORTE OD/PO

5) TAB. Benfotiamine 100mg/OD/PO.

6) oint. Ketoconazole L/A.