CASE -8

A 55 year old patient of labour in occupation and resident of suryapet came to hospital with compliants of difficulty in speech and right hemiparesis.
CHIEF COMPLAINTS:
Difficulty of speech since 6 hours 
Weakness in righ upper and lower limbs since 8 hrs
Deviation of angle of mouth since 8 hrs
HOPI:
Patient was asymptomatic 6 hrs ago before reaching the hospital then he developed difficulty in speech and weakness in right upper and lower limbs and devation of angle of mouth since 6 hours 
NO H/O drooling of saliva, loss of consciousness and involuntary movements in the body
NO H/O 
Constipation
Vomiting
Burning micturation
SOB
Pain in the abdomen
Loose stools
PAST HISTORY:
History of hydrocele sugery 6 months back 
History of CVA 3 Years back in which his right upper limb is paralyzed forwhich he is received medication and was improved.
H/O HTN Since 2 years for which he was on medication using Atorvas-tg 10mg 
No  H/O  of TB, ASTHAMA , THYROID DISORDERS,Blood transfusions.
PERSONAL HISTORY:
Appitite- Normal
Diet- mixed
Sleep - regular
No allergies
Bowel movements are regular and normal
ADDICTIONS:
alcohol : daily consumes 3-5 units of whiskey 
Since 20 years
Tobocco:  has a habit of smoking since 15 years.
FAMILY HISTORY:
No significant family history

GENERAL EXAMINATION:
Patient was conscious, coherant,co- operative amd well oriented.
Moderately built
Moderately nourished 
No pallor
No icterus
No lymphadenopathy
No pedal edema
No clubbing
No cynosis.

CNS EXAMINATION:
Patient was not able to speak
His level of consciousness is good
No hellucinations or delusions noted.
No signs of neck stiffness noted.
MOTAR EXAMINATION: 
  Tone of the muscle:
                                      RIGHT.              LEFT
Upper limbs :.              Negetive          normal      Lower limbs :.              Negetive.         normal   
Power of the muscle:
                                     
 Biceps :                          0.                    5
triceps :.                          0.                    5
Wrist.  :.                           0.                    5
Hip.   :.                             0.                    5
Knee. :.                            0.                     5
Ankle.                               0.                     5

Reflexes:
Knee jerk.  -                     absent.           Present
Ankle jerk -.                     Absent.          Present
Biceps reflex -.                Absent.          Present
Triceps reflex-.               Absent.           Present
BABISKIES.   -.                Absent.           Present

SENSORY EXAMINATION:
All higher motor functions
Speech- not good
Taste- normal
Smell-  normal
Pain- is Ellicited
Touch - is Ellicited

CRANIAL NERVES:
  All 12 cranial nerves are normal and intact

AUTONOMUC NERVEOUS SYSTEM EXAMINATION:
Not able to feel bladder fullness
Unable to stop urine in midstream
Not able to complete evacuation of urine in bladder without dribbing on which he's now with introduced to cathetor and urine bag
No sweating and palpitations 


CVS EXAMINATION:
Heart sounds - S1 AND S2 Heard
No cardiac murmurs
Apex normally placed

RESPIRATORY SYSTEM EXAMINATION:
Chest symmetrical
No paradoxical movements, 
Normal vesicular breath sounds heard,
No abnormal/added sound

ABDOMEN EXAMINATION :
 Abdomen is soft, No organomegaly, No ascites.

INVESTIGATIONS:
Provisional diagnosis:
Right hemiparesis with recurrent CVA
Presence of infrant in left frontal region in CT scan

Medication and treatment :














 






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