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 

https://youtu.be/zrt4OHMCAQs


https://youtu.be/WJFYJ3P8ipE

Romberg sign - slaying to right 

https://youtu.be/BEmiwYQZe0M



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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