Acute ischemic infarct with UMN facial palsy
I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan
K.shirisha
Rollno;68
50yr old male came with cheif complaints
Of weakness of right upper limbs and lower limbs
Of swelling on Rt leg since 7days
C/o fever since 1 week
HOPI- patient was apparently asymptomatic 10days ago the he had sudden weakness of right U/L and L/L and slurred speech which he sought for consultation and was diagnosed as Rt hemiparesis
H/o fever 10 days ago which was insidious onset gradually progressive not associated with chills and rigor .no diurnal variation
H/O 3episodes of vomiting non projectile food particles ascontents with hiccups
H/o headache, giddiness
Patient has h/o injury to the right big toe 7days back, because of weakness of rt upper limb and lower limb followed by swelling of right leg associated with low grade fever not associated with chills, patient sought for consultation and now admitted for further management and treatment
K/c/o CVA- Rt hemispheres 10days ago
Past history- k/c/o HTN,DM since 6months
H/o CVA- right hemiparesis - 10days ago
No h/o CAD, epilepsy , tb , asthma
Personal h/o -
Appetite: normal
Diet: mixed
Bowel and bladder: regular
Sleep: adequate
Addictions
he is occasionalbidi smoker for past 30years
Regular bidi smoker since 3years (2-3/day)
Occasional alcoholic since 35years
General examination:
Patient was conscious,coherent cooperative
Pallor: absent
Icterus: absent
Cyanosis: absent
Clubbing: absent
Lymphadenopathy: absent
Edema: absent
Vitals
BP- 140/80mmhg
PR- 78bpm
RR- 16cpm
Temp- Afebrile
CNS
Gait: https://youtu.be/BEmiwYQZe0M
Speech : normal
Higher mental functions
Power - Right - Left
U/L. 4/5. 5/5
L/L. 5/5. 5/5
Reflexes B T S K A. P
Right +++ ++ +. +++. +. Mute
Left ++. ++. +. ++. - Flexion
Cerebellar signs RT Left
Disdichokinesis. able not Able
https://youtube.com/shorts/WhAxDe4KdRA?feature=share
https://youtube.com/shorts/PVe9O0FpiPI?feature=share
Finger nose Absent. Present
Knee heel. Absent. Present
Romberg sign - slaying to right
Cranial nerve examination
• 1 - olfactory sense - normal
• 2- Direct and indirect light reflex present
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present
• 7- deviation of mouth to right
, no loss of nasolabial folds,
forehead wrinkling present on right side
• 8. : Normal hearing
• 9,10- position of uvula is towards left,
Gag reflex- present
• 11- sternocleidomastoid contraction present
• 12- no deviation of tongue
SENSORY SYSTEM
I – SPINOTHALAMIC R L
1. Crude touch N N
2. Pain. N. N
3. Temperature. N. N
II – POSTERIOR COLUMN
1. Fine touch. N. N
2. Vibration. N. N
3. Position sense. N. N
4. Romberg’s sign - swaying towards right
III – CORTICAL
1. Two point
discrimination. N. N
2. Tactile localisation. N. N
3. Graphaesthesia. N. N
4. Stereognosis. N. N
No meningeal signs found
On1/1/23
HMF INTACT
POWER RT LT
U/L 5/5 5/5
L/L 5/5 5/5
REFLEXES : BI TRI SUP KN ANK PLAN
RT ++ ++ + +++ + MUTE
LT ++ ++ + ++ - FLEXOR
CEREBELLAR SIGNS-
Rt. Lt
Dysdikokinesia. not able able
Finger nose + +
Knee heel. + +
Rombergs -. Swaying to right
NO MENINGEAL SIGNS
CVS- S1s2 present ; no murmurs heard
RS- bilateral air entry present
No added sounds heard
PerAbdomen- soft; non tender
Bowel sounds heard
CVS: S1,S2 heared, no murmurs
Diagnosis - acute ischemic infarct secondary to ? Emboli in ACA,MCA territoty
Right hemiparesis ( resolved)
UMN facial palsy
2. With mild hemorrhagic foci in left Pontal region
3. Right lower limb cellulitis
4. Known case of type 2 DM since 6months & known case of hypertension -6months
Investigations:
HB: 13.7. -. 13.9. - 14.1
TLC: 5,700. - 6,499. - 6,100
PC: 2.10lakh. - 2.25 lakh. - 2.26lakh
N: 50
L: 43
E: 04
M: 05
B: 0
Impression; Normocytic normochromic blood picture
Cue:
Pale yellow,clear
Albumin: nil
Sugars:4+
Puscells: 4-5
Epithelial cells: 2-4
Lft:
TB: 1.00
DB:0.19
AST: 11
ALT:18
ALP:157
TP: 6.1
Albumin:3.1
RFT:
Blood urea: 33. - 30
Sr.creatinine: 0.9. - 0.9
Na: 134. - 132
K: 3.9. - 4.6
Cl: 102. - 104
ICA: 1.01. - 0.84
Hba1c:7.0
FBS: 181
Lipid profile:
Total cholesterol: 205mg/dl
Tg: 377mg/dl
Hdl: 62mg/dl
Ldl: 120mg/dl
USG abdomen
Findings: E/O 18x15mm anechoic cyst noted in upper pole of right kidney
Right simple renal cortical cyst
Grade - 1 fatty liver
2d echo:
EF:64%
Trivial TR/AR, no mR
No RWMA,noAS/MS.sclerotic AV
Good lv systolic function
Diastolic dysfunction,no pAH/pe
MRI brain( plain):
ECG:
Treatment:
1.Tab Augmentin 625 mg/po/Bd
2. Tab metrogyl 600mg/po/Tid
3.Tab ECOSPRIN AV 75/40 /po/HS
4.Tab GlimiM1/po/Bd
5.Tab. neurobin forte po/od
6. Tab chymeral forte po/Tid
7.T Dolo 650 mg/ po/Tid
8. Regular dressings of lower limbs
9. RT lower limb elevation
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