A CASE OF LEFT HEMIPARESIS

MEDICINE CASE DISCUSSION

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I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.  

45 year old male patient presented with left hemiparesis secondary to acute infract in right MCA territory-mainly fronto parietal occipito region,insular cortex,adjacent corona radiata with k/c/o dm 2since 10 years.

CHEIF COMPLAINTS :

Patient was brought to casuality with c/o deviation of mouth to right side since yesterday night ,weakness of left upper limb and lower limb since morning .

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic  till yesterday night  ,then deviation of mouth towards right side and today morning patient had difficulty walking due to which they visited a local hospital and was treated conservatively and symptoms did not subside  and weakness progressed 

No h/o slurring of speech ,drooling of saliva 

No h/o loss of consciousness,nystagmus,

No h/o head trauma 

H/o fever ,low grade since 2days not associated with cough ,headache ,vomitings

H/o alcohol consumption since 15years 

2013- patient had complaints of polyuria ,went to hospital and was diagnosed diabetic.

Joint pains since 1week which was relieved on medication.

H/o of occasional shock like pain along shoulder(lt)since 6 months.

K/c/o DM since 10years on tab glimi twice daily

N/k/c/o HTN(180/110)@admission ,CAD ,thyroid epilepsy.

PERSONAL HISTORY:

Diet: mixed 

Appetite: normal

Sleep: Adequate 

Bowel and bladder: Regular 

Alcohol intake since 15-20 years (180 ml per day)

GENERAL EXAMINATION:

No pallor,No icterus, cyanosis, clubbing, lymphadenopathy,edema.

Vitals:

PR-105 bpm

RR- 25 cpm

Temp-99F

Bp-180/110 mmhg 

Spo2-98 RA 

GRBS-204 mg/dl

SYSTEMIC EXAMINATION ::

GIT

INSPECTION :

Abdomen - scaphoid 

Umbilicus - inverted 

Movements - all quadrants are equally moving with respiration.

No scars and sinuses 

No visible peristalsis

No engorged veins.

PALPATION:

No local rise in temperature and no tenderness in all quadrants 

LIVER: no hepatomegly

SPLEEN- not enlarged 

KIDNEYS - bimanual palpable kidneys 

PERCUSSION :

no shifting dullness

AUSCULTATION :

Bowel sounds are heard and are normal

No bruit

Respiratory system:

Inspection:

No tracheal deviation 

Chest bilaterally symmetrical with pectum excavatum 

Type of respiration: thoraco abdominal.

No dilated veins,pulsations,scars, sinuses.

No drooping of shoulder.

Palpation:

No tracheal deviation

Apex beat- 5th intercoastal space,medial to midclavicular line.

Tenderness over chestwall- absent.

Vocal fremitus- normal on both sides.

Percussion:                   

Supraclavicular            

Infraclavicular.         

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Interscapular

Right side and left side- resonant in above areas.

Auscultation:

Bilateral Airway entry - present

Cardiovascular system:

Inspection : no visible pulsation , no visible apex beat , no visible scars.

Palpation: all pulses felt , apex beat felt.

Percussion: heart borders normal.

Auscultation: 

Mitral area, tricuspid area, pulmonary area, aortic area- S1,S2 heard.

Central Nervous system:

Higher motor functions- Intact 

Cranial nerve functions - Rt.Lower facial nerve weakness +[mouth deviation to Rt.]

Sensory system-Normal(fine and crude touch, proprioception,vibration)

Motor system.             Right  Left    

                    Power- UL 4/5  1/5

                                 LL 4/5  1/5 

                              Neck  N     N

              Trunk muscles   Normal

                Tone- UL Normal  decrease

                         LL Normal     Decrease

          Reflexes- 

Superficial reflexes - Intact 

                    Plantar flexion  extension

Deep tendon reflexes -

                           Biceps   ++    +++

                           Triceps   ++   +++

                         Supinator  +   ++

                                Knee  ++   + ++

                             Ankle     +    ++

Cerebellum 

Romberg: negative

Finger nose in coordination :absent

Dysdiadochokinesia : absent

INVESTIGATIONS: 

DIAGNOSIS:

LEFT HEMIPARESIS 2o TO ACUTE INFARCT IN RT. MCA TERRITORY -MAINLY FRONTO PARIETAL OPERCULUM,PARIETO OCCIPITAL REGION ,INSULAR CORTEX , ADJACENT CORONA RADIATA;K/c/o Dm2 SINCE 10 YEARS.

TREATMENT :

1. RT FEEDS 100 ml 2nd hourly

  MILK + PROTEIN POWDER 4 th hourly

 2.IV FLUIDS NS @ 25ml/hr

3.INJ.  THIAMINE 200 mg in 100 ml NS IV BD

4.INJ HAI ACC TO GRBS

5.TAB.ECOSPIRIN-AV (75/10)PO HS

6. TAB. AMLODIPINE 5mg PO/OD 8 am

7.TAB. DOLO 650MG PO SOS

8.T.LORAZEPAM 2mg 

9.T. BACLOFEN XL 20 mg