case 18 - 37 year male with subacute infarct right lentiform nucleus and hypertensive urgency

 37 yr old male came with c/o tingling sensation in left upper and lower limb Numbness prsent Slurring of speech present lasting for 1-2 mins Pt was apparently asymptomatic till yesterday afternoon where patient developed tingling sensation and numbness associated with slurring of speech lasting for 1-2 mins 

No h/o deviation of mouth ,unable to lift left upper and lower limb ,drooping of eyelid or loss of labial fold 2nd episode - similar episode occured in the evening around 6 pm later today morning they went to local doctor 
O/E: bp was 210/140mmhg Routine investigation were done
 Ct brain was done which was given as normal they were referred  for further management 
 No significant past history 
 No similar complaints in past 
 Not k/c/o T2 DM,HTN,asthma ,tb,epilepsy 

Personal: Pt has mixed diet  
No loss of appetite
 Bowel and bladder movements regular 

 O/e : pt is c/c/c 
Afebrile to touch  
Pr -110bpm 
Bp -220/130 mmhg 
 Rr- 20cpm 

Cvs - s1s2 heard ,no murmers

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

 P/a - soft,non tender ,no organomegaly 

CNS :

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           N

Lower limb           N          N


Power                   R.           L

Upper limb.       5/5          5/5

Lower limb.      5/5           5/5

Reflexes              R                L

         B                  1+             --    

         T                  --               1+

         S                  --               --

         K                 1+              1+

         A                 1+               1+

         P             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 :



Cue findings 

 Lft : 


 RFT-
 

Serology - negative 
Chest xray normal 


 Ecg- normal 

Mri brain



Treatment : 
1.tab ecosporin 150mg/po/Hs
 2.tab clopitab 75mg /po/hs 
3.tab atorvastatin 40mg /po/hs 
4.inj pan 40mg/iv /od 
5 inj optineuron 1amp in 100ml ns iv/od 
 6.tab nicardia 20mg /po/stat
 7.inj lasix 40mg /iv/stat 
8.tab telma 40mg /po/od 
9.strict bp /pr monitoring hourly 
 10.grbs 10th hrly

Day1:
No fresh complaints 

O/e : pt is c/c/c 
Afebrile to touch  
Pr -98bpm 
Bp -190/100 mmhg 


 Rr- 19 cpm 
Cvs - s1s2 heard ,no murmers
Rs-b/l air entry present ,no added sounds
P/a - soft,non tender ,no organomegaly 

CNS :

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           N

Lower limb           N          N


Power                   R.           L

Upper limb.       5/5          5/5

Lower limb.      5/5           5/5

Reflexes              R                L

         B                  1+             --    

         T                  --               1+

         S                  --               --

         K                 1+              1+

         A                 1+               1+

         P             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:

FLP:


2decho:

Fundoscopy:




Treatment : 

1.tab ecosporin 150mg/po/Hs
 2.tab clopitab 75mg /po/hs 
3.tab atorvastatin 40mg /po/hs 
4.inj pan 40mg/iv /od 
5 inj optineuron 1amp in 100ml ns iv/od 
 6.tab nicardia 20mg /po/stat
 7.inj lasix 40mg /iv/stat 
8.tab telma 40mg /po/od 
9.strict bp /pr monitoring hourly 
 10.grbs 10th hrly

Day2 :

No fresh complaints 

O/e : pt is c/c/c 
Afebrile to touch  
Pr -98bpm 
Bp - 180/100mmhg 


 Rr- 19 cpm
I/O:770ml/800ml
Cvs - s1s2 heard ,no murmers
Rs-b/l air entry present ,no added sounds
P/a - soft,non tender ,no organomegaly 

CNS :

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           N

Lower limb           N          N


Power                   R.           L

Upper limb.       5/5          5/5

Lower limb.      5/5           5/5

Reflexes              R                L

         B                  1+             --    

         T                  1+             1+

         S                  --               --

         K                 2+               2+

         A                 1+               1+

         P             MUTE            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:

S urea-51

S.creat -1.2

Treatment : 

1.tab ecosporin 150mg/po/Hs
 2.tab clopitab 75mg /po/hs 
3.tab atorvastatin 20mg /po/hs 
4.tab pan 40mg/po/od 
5 inj optineuron 1amp in 100ml ns iv/od 
 6.tab nicardia 20mg /po/stat
 7.inj lasix 40mg /iv/stat 
8.tab telma 80mg + H(12.5) OD
9.tab cilinidipine 10mg po od
 10.tab atenelol 50mg od/po

Day3:

No fresh complaints 

O/e : pt is c/c/c 
Afebrile to touch  
Pr -80bpm 
Bp - 210/110mmhg 
 Rr- 19 cpm
I/O:950ml/400ml
Cvs - s1s2 heard ,no murmers
Rs-b/l air entry present ,no added sounds
P/a - soft,non tender ,no organomegaly 

CNS :

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           N

Lower limb           N          N


Power                   R.           L

Upper limb.       5/5          5/5

Lower limb.      5/5           5/5

Reflexes              R                L

         B                  1+             --    

         T                  1+             1+

         S                  --               --

         K                 2+               2+

         A                 1+               1+

         P             MUTE            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:

ESR-10 

THYROID:

Treatment : 

1.tab ecosporin 75mg/po/Hs
 2.tab clopitab 75mg /po/hs 
3.tab atorvastatin 20mg /po/hs 
4.tab pan 40mg/po/od 
5.tab neurobion forte po od
6.tab METXL 25 mg  po od
7.tab telma 80mg + H(12.5) OD
8.tab cilinidipine 10mg po od
9.tab atenelol 50mg od/po
10.strict pr/bp charting 2nd hrly 
11.grbs 8th hrly

Day4:

No fresh complaints 

O/e : pt is c/c/c 
Afebrile to touch  
Pr -81bpm 
Bp - 180/80mmhg 
 Rr- 19 cpm
I/O:650ml/900ml
Grbs-96mg/dl
Cvs - s1s2 heard ,no murmers
Rs-b/l air entry present ,no added sounds
P/a - soft,non tender ,no organomegaly 
Cns;NFD

Treatment : 

1.tab ecosporin 75mg/po/Hs
 2.tab clopitab 75mg /po/hs 
3.tab atorvastatin 20mg /po/hs 
4.tab neurobion forte po od
5.tab METXL 25 mg  po od
6.tab telma 80mg + H(12.5) OD
7.tab cilinidipine 10mg po bd
8.strict pr/bp charting 2nd hrly 
9.grbs 8th hrly

Day5:
No fresh complaints 
O/e : pt is c/c/c 
Afebrile to touch  
Pr -96bpm 
Bp - 220/110mmhg 
 Rr- 18 cpm
Cvs - s1s2 heard ,no murmers
Rs-b/l air entry present ,no added sounds
P/a - soft,non tender ,no organomegaly 
Cns-NFD
Treatment : 
1.tab clinidipine 10mg po/bd
2.ta amlong 10mg po/od 
3.tab atenolol 50mg po/od 
4.bp/pr chart hourly
5.tab ecosporin gold (75/75/20)hs
6.tab neurobion forte od po
7.grbs 8th hrly

Day 6:
No fresh complaints 
O/e : pt is c/c/c 
Afebrile to touch  
Pr -84bpm 
Bp - 190/110mmhg 


 Rr- 18 cpm
Grbs-100mg/dl
I/O-750/1100
Cvs - s1s2 heard ,no murmers
Rs-b/l air entry present ,no added sounds
P/a - soft,non tender ,no organomegaly 
Cns-NFD
Treatment : 
1.tab clinidipine 10mg po/bd
2.ta amlong 10mg po/od 
3.tab atenolol 50mg po/od 
4.bp/pr chart hourly
5.tab ecosporin gold (75/75/20)hs
6.tab neurobion forte od
7.grbs 8th hrly


Day 7:
No fresh complaints 
O/e : pt is c/c/c 
Afebrile to touch  
Pr -96bpm 
Bp - 180/100mmhg 


 Rr- 18 cpm
Cvs - s1s2 heard ,no murmers
Rs-b/l air entry present ,no added sounds
P/a - soft,non tender ,no organomegaly 
Cns-NFD
Treatment : 
1.tab clinidipine 10mg po/bd
2.ta amlong 10mg po/od 
3.tab atenolol 50mg po/od 
4.bp/pr chart hourly
5.tab ecosporin gold (75/75/20)hs
6.tab neurobion forte od
7.grbs 12th hrly


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