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
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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