case 17 - A 60 yer old female cva with left hemiplegia with left UMN FACIAL PALSY?MCA TERRITORY WITH K/C/O DM2,HTN

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Here is a case i have seen:

A 60 year old female came with
C/o weakness of left upper limb and lower limb since yesterday evening @7pm
C/o deviation of mouth to right
H/o fever since 10days back and cold since 10days back
Patient was apparently asymptomatic 10days back uthen developed cold and fever which is insidious in onset gradually progressive associated with chills and rigors,subsided on taking medication from an local rmp
C/o burning mictuaration since 10days
No c/o sob ,dyspnea,chest pain ,headache,pedal edema ,giddiness,syncope,vomiting,nausea,abdominal pain ,decreased urine output
K/c/o dm since 6 months and htn since 3years on regular medications
For DM(t.metformin 500mg)
For HTN(T.amlong)
No h/o asthma,tb,epilepsy
Personal :
Pt was on mixed diet
No loss of apetite
Bowel and bladder movements regular
No addictions
O/E:pt is drowsy,arousable
No pallor,icterus,clubbing,cyanosis,
lymphadenopathy ,edema
Pt was afebrile
PR-84 bpm
BP-120/70 mmhg
RR-26 cpm

Cns-pt is drowsy,arousable

orientated to time, place, person

Higher mental functions intact

Speech normal

Memory immediate+, recall+, recent+

Cranial nerves - normal

Motor system:

Bulk                       R.           L

Upper limb.          N           N

Lower limb           N          N

Tone                       R.           L

Upper limb.          N           decreased

Lower limb           N          decreased


Power                   R.           L

Upper limb.       4/5          0/5

Lower limb.      4/5           0/5

Reflexes              R                L

         B                  2+             3+  

         T                  --               --

         S                  --               --

         K                 2+              --

         A                 --                --

         P           decreased      mute

Superficial:

                    Corneal present

                    Conjunctival present

                   

SENSORY

1.Posterior column

Proprioception             R.           L

Upper limb.                    +            +

Lower limb.                    +           +

                                   

Fine touch                      R.           L

Upper limb.                    +            +

Lower limb.                    +           +                      

Vibration                        R.           L

Upper limb.                    +            +

Lower limb.                    +           +  

Joint position                   R.           L

Upper limb.                      +            +

Lower limb.                      +           +  


2.Anterior spinothalamic tract

Pain.                             R              L

Upper limb                 +               +

 Lower limb                +               +

Temperature               R              L

Upper limb                  +               +

 Lower limb                +               +

Crude touch                 R              L

Upper limb                  +               +

 Lower limb                +               +

3.cortical 

2 point discrimination  + 

Stereognosis                    +

Cerebellum:

Rombergs test                    -- 

No finger nose in coordination

No finger finger incoordination

Dysdiadokinesia             -  absent

Rebound phenomenon-  absent

Nystagmus                       - absent 

Pendular knee jerk        - negative

Heel shin test                  -negative


Investigations:
CBP:

Hb -9.7

TLC-9100

PLT-2.59

Urine for ketone bodies - negative
CUE



ABG



RFT




CHEST XRAY 


Ecg



treatment:
1.ryles cathterization
2.head end elevation
3.RT feed - 100ml milk 2nd hrly -1200
- 50 ml water hrly -1200
4.inj pantop 40mg/iv/od
5.oxygenation to maintain spo2>90%
6.syp GRILLINCTUS 10ml TID
7.inj HAI -S/C

Day2:c/o one episode of high grade fever 

8:00am (101f)

O/E:pt is drowsy,arousable
No pallor,icterus,clubbing,cyanosis,
lymphadenopathy ,edema
Pt was afebrile 
PR-80 bpm
BP-110/70 mmhg

Grbs-192mg/dl

I/O: 1600/2250

Cvs-s1s2 heard ,no murmers

Rs-b/l air entry present ,no added sounds 

P/a- soft,non tender ,no organomegaly 

Cns-pt is drowsy,arousable

orientated to time, place, person

Higher mental functions intact

Speech normal

Memory immediate+, recall+, recent+

Cranial nerves - normal

Motor system:

Bulk                       R.           L

Upper limb.          N           N

Lower limb           N          N

Tone                       R.           L

Upper limb.          N           decreased

Lower limb           N          decreased


Power                   R.           L

Upper limb.       4/5          0/5

Lower limb.      4/5           0/5

Reflexes              R                L

         B                  2+             3+  

         T                  --               --

         S                  --               --

         K                 2+              --

         A                 --                --

         P           decreased      mute

Superficial:

                    Corneal present

                    Conjunctival present

                   

SENSORY

1.Posterior column

Proprioception             R.           L

Upper limb.                    +            +

Lower limb.                    +           +

                                   

Fine touch                      R.           L

Upper limb.                    +            +

Lower limb.                    +           +                      

Vibration                        R.           L

Upper limb.                    +            +

Lower limb.                    +           +  

Joint position                   R.           L

Upper limb.                      +            +

Lower limb.                      +           +  


2.Anterior spinothalamic tract

Pain.                             R              L

Upper limb                 +               +

 Lower limb                +               +

Temperature               R              L

Upper limb                  +               +

 Lower limb                +               +

Crude touch                 R              L

Upper limb                  +               +

 Lower limb                +               +

3.cortical 

2 point discrimination  + 

Stereognosis                    +

Cerebellum:

Rombergs test                    -- 

No finger nose in coordination

No finger finger incoordination

Dysdiadokinesia             -  absent

Rebound phenomenon-  absent

Nystagmus                       - absent 

Pendular knee jerk        - negative

Heel shin test                  -negative


Investigations:
CBP:

Hb -10.3

TLC-10,900

PLT-2.07

FBS-213

Hba1c-8.1

USG ABDOMEN 


2decho:




treatment:
1.propped up position 
2.frequent position change
3.RT feed - 100ml milk 2nd hrly -1200
                  - 50 ml water hrly -1200
4.inj pantop 40mg/iv/od
5.IVF -NS @50ml/hr
6.tab ecosporin-av(75/20mg)
7.inj HAI -s/c 


Day3:c/o one episode of high grade fever 8:00am,8pm     ,8am

101      ,102       ,99.8

O/E:pt is drowsy,arousable
No pallor,icterus,clubbing,cyanosis,
lymphadenopathy ,edema
Pt was afebrile 
PR-86 bpm
BP-120/80 mmhg

I/O: 4200/3350

Cvs-s1s2 heard ,no murmers

Rs-b/l air entry present ,no added sounds 

P/a- soft,non tender ,no organomegaly

Cns-pt is drowsy,arousable

orientated to time, place, person

Higher mental functions intact

Speech normal

Memory immediate+, recall+, recent+

Cranial nerves - normal

Motor system:

Bulk                       R.           L

Upper limb.          N           N

Lower limb           N          N

Tone                       R.           L

Upper limb.          N           decreased

Lower limb           N          decreased


Power                   R.           L

Upper limb.       4/5          0/5

Lower limb.      4/5           0/5

Reflexes              R                L

         B                  2+             3+  

         T                  --               --

         S                  --               --

         K                 2+              --

         A                 --                --

         P           decreased      mute

Superficial:

                    Corneal present

                    Conjunctival present

                   

SENSORY

1.Posterior column

Proprioception             R.           L

Upper limb.                    +            +

Lower limb.                    +           +

                                   

Fine touch                      R.           L

Upper limb.                    +            +

Lower limb.                    +           +                      

Vibration                        R.           L

Upper limb.                    +            +

Lower limb.                    +           +  

Joint position                   R.           L

Upper limb.                      +            +

Lower limb.                      +           +  


2.Anterior spinothalamic tract

Pain.                             R              L

Upper limb                 +               +

 Lower limb                +               +

Temperature               R              L

Upper limb                  +               +

 Lower limb                +               +

Crude touch                 R              L

Upper limb                  +               +

 Lower limb                +               +

3.cortical 

2 point discrimination  + 

Stereognosis                    +

Cerebellum:

Rombergs test                    -- 

No finger nose in coordination

No finger finger incoordination

Dysdiadokinesia             -  absent

Rebound phenomenon-  absent

Nystagmus                       - absent 

Pendular knee jerk        - negative

Heel shin test                  -negative


Investigations:
CBP:

Hb -10.4

TLC-11,500

PLT-2.24

Smear for malarial parasite- negative

treatment:
1.propped up position 
2.frequent position change
3.RT feed - 100ml milk 2nd hrly -1200
                  - 50 ml water hrly -1200
4.inj pantop 40mg/iv/od
5.IVF -NS @50ml/hr,RS @50ml/hr
6.tab ecosporin-av(75/20mg)od
7.inj HAI -s/c 

8.syp lactulose 30ml bd





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