A 71 year old male patient with the cheif complaints of weakness in right upper limb

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71 year old male came to hospital  with chief  complaints of weakness in right upper limb since  4 days and slurring of speech since 3 days

HOPI:  patient is known case of cerebrovascular accident

1 year back associated with  bilateral upper limb

 weakness he was given medications and sent back  

He used the medication for about 5 months and then 

Stopped taking drugs.

5 years back he gives history  of chest pain  squeezing type  and , he  was admitted to   the 

 

Hospital PTCA  was done to manage the patient.

3 days back he woke up from sleep and noticed 

Numbness and tingling sensations in the both hands , 

He noticed that he was unable to eat the food with hand,

He was not able to make fist , weakness in lifting the 

Right hand 

From 2 days he has slurring of speech 

He has no H/o fever, trauma , nausea, vomiting,infections, seizures ,loss of consciousness 

Daily activities: he used to wake up by 6 o clock in the 

Morning,used to complete daily activities 

Past History : No History of diabetes, hypertension  seizures, asthma, TB ,

Personal history:  DIET: Mixed

Appetite : normal

Bowel and bladder movements : regular

Sleep : inadequate

Addictions:  chronic beedi smoker for about 40 yrs 

Occasionally consumes alcohol 

Family History:  not Significant  

Treatment history : he was taking lipid lowering and anti platelet drugs and stopped 5 months back

Surgical history: he  was treated with minimally invasive procedure PTCA about 5 years back.

General Examination: 

Patient is Conscious,  Cooperative and is oriented to time, Place and Person.

 He is moderately Built and Nourished

.

Pallor :Absent

Icterus: Absent

Clubbing : present 

Cyanosis :Absent

Lymphadenopathy :Absent

Edema:Absent

Vitals : 

Temperature - afebrile

Pulse- 90 bpm

B.P -110/80 mm Hg 

RR - 18 cpm

SYSTEMIC EXAMINATION : 

CVS : S1 S2 heard, no murmurs

RS : Bilateral air entry present, normal vesicular breath sounds, no added sounds

GIT : Soft, non-tender, no organomegaly

CNS EXAMINATION: 

Dominance - Right handed

Higher mental functions

   

  • conscious

    • oriented to person and place

    • memory - able to recognize their family members

Patient is emotionally stable and his behaviour and appearance  is appropriate 

Slurring of speech is present 

Recent immediate and remote memory is intact

Cranial nerve examination 

   • 1 - normal 

    • 2- Direct and indirect light reflex present

- Rt - No perception of light. Non reactive pupil.

             Extraocular movemts are normal

Lt - Light reflex is present.  He is able to count fingers at 6 m

    • 3,4,6 - no ptosis Or nystagmus

    • 5- corneal reflex present 

    • 7- slight  deviation of mouth, loss of nasolabial folds, forehead wrinkling present

   • 8- able to hear

   • 9,10-  normal 

   • 11- sternocleidomastoid contraction present

•12 - no tongue deviation 

Motor system :

 Attitude - 

Tone -  normal tone on right side(both UL,LL)

            Normal tone on left side(UL,LL)

Power: 

     Right            Left  

               

UL 3/5             4/5

LL. 4/5              4/5

Reflexes :      superficial reflexes : corneal reflex, conjunctival reflex, abdominal reflex , plantar reflex  present 

On both sides,

      

                Right              left 

Biceps     2 +                 2+

Triceps         2 +             2+

Knee jerk  2+                  2+ 

Ankle jerk  .     1+            1+ 

Supinator    2+                 2+

Sensory examination: 

Crude  touch : normal 

Pain: normal

Temperature: normal

Fine touch : normal

2 point discrimination: normal 

Stereognosis: normal 

Cerebellar signs : 

Knee heel test, finger nose test , dysdiadokokinesia

All test findings are normal.

Clinical pictures

  

Investigations: ECG : 

HBs Ag - non reactive

Serology - negative

MRI BRAIN: 

Carotid doppler

2 d echo

 

Provisional diagnosis: recurrent cerebrovascular accident? 

Treatment :  iv  fluids

Tab ecosprin

Lactulose

Tab pantaprazole 

Tab Atorvastat

Monitor vitals