50 year old male with stroke

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A 50year old male patient  from   naryanapuram   Presented to casualty(29-06-22)with the chief complaint  of giddiness and weakness in both lower limbs since afternoon.              

HOPI:

Patient was apparently asymptomatic 1day back then he developed headache and dizziness for 30min on and off in the early morning but still he went to perform  his daily work activities (i.e.agriculture) from the afternoon then he had  a deviation of mouth towards right side with giddiness and weakness in both lower limbs.

 He also have pain in the right side of the face

H/o of vomiting(3episodes) which non bilious and non projectile since morning 

From today morning there is difficulty in walking i.e swaying on right side

 h/o slurred speech, no h/ourinary incontinence,

No h/o loss of consciousness (to rule out brainstem involvement)

No h/o transient loss of vision (to rule out TIA)

no h/o fever, night sweats, weight loss

No h/o head /spine trauma

No h/o involuntary movement

No h/o palpitations and sob 

No h/o double vision (3,4,6 cranial nerve)

No h/o tinitus(8th cranial nerve)

No h/o difficultly in swallowing ,nasal regurgitation,hoarness of voice (9,10)

No h/o altered sensorium and behaviour changes

 Daily routine 

The patient wakes up at around 4 am and completes his daily morning activities. He is farmer  by occupation  At around 9:00am he goes back to work and come back home at around 6 pm. He has food and sleeps by 9 pm.

Past history:

H/o hypertension from the past 4years

No h/o diabetes, asthma,tb, epilepsy

No similar complaint in the past

Drug history:

He take anti -HTN drug only when he feels anxiety and weakness in the limbs

Family history:no similar complaint in the family

Personal history

Diet:mixed

Appetite: normal 

Bowel and bladder: regular 

Sleep: reduced

Addiction: occasionally he drinks Alcohol

Examination

General examination 

No pallor, icterus, clubbing, lymphadenopathy ,edema

Vitals

BP:150/100(lft arm)

PULSE RATE:82/min

RESPIRATORY RATE:20cycles/min

TEMPARATURE:afebrile

CNS EXAMINATION

Right handed person 

HIGHER MENTAL FUNCTION

Counsious ,oreinted to time place person

Speech normal

Behaviour normal

Memory intact 

Intelligence normal 

Lobar function normal

CRANIAL NERVE EXAMINATION

  -OLFACTORY-normal

 - optic : normal visual field on the right side 

Left side slight reduced vision from childhood due to trauma

 - oculomotor,trochlear,abducens-intact

Facial nerve unable to smile

 - vestibulocochlear- intact

 - glossopharyngeal -intact

  - vagus-intact

  -accesory spinal ganglion nerve intact

  - hypoglossal intact

Sensory system:

-fine touch: intact

-pain: normal 

-temperature  - normal

- vibration -normal

-stereognosis-

-two point discrimination-present

Motor system examination

Nutrition -

U/L.         R.             L

            Normal.    Normal

L/L.     Normal.       Normal

ANY ATOPHY-

TONE:

        U/L.               R.          L.

   

                      Hypotonia.    Normotonia

         L/L 

                      Normotonia.  Normotonia 

    

  

POWER.            RIGHT.           LEFT.

SHOULDER

 flexion  :               5/5    5/5

 Extension        5/5.  5/5

Abduction     5/5.  5/5

Adduction         5/5.    5/5

Internal rotation 5/5.   5/5

External rotation    5/5.   5/5

Elbow:5/5.    5/5

Flexion.     5/5.   5/5

Extension:5/5.   5/5

Wrist:5/5.  5/5

Flexion:5/5.   5/5

Extension:5/5.   5/5

Abduction : 5/5.   5/5

adduction:5/5.   5/5

Hip

Flexion:5/5.    5/5 

Extension.  5/5.   5/5

Abduction:5/5.   5/5

Adduction 5/5.    5/5

Internal rotation:5/5.    5/5

External rotation.  5/5.    5/5

Knee 5/5.     5/5

Flexion 5/5.    5/5

Extension.   5/5.   5/5 

Ankle.  5/5.     5/5

Plantarflexion:.   5 /5.    5/5

Dorsiflexion.     5/5.  5/5

Toe.   5/5 5/5

Movements:5/5

REFLEXES: 

Corneal present 

Conjunctival  present 

Abdominal: present 

Plantar: present 

DEEP REFLEXES:

Biceps : 5+.   5+

Triceps 5+.   5+

Knee : 5+.      5+

Ankle: 5+.   5+

CEREBELLAR 

NYSTAGMUS absent

DYSADEADOCHOKINESIA absent 

FINGER NOSE tip- unable to perform

https://youtube.com/watch?v=de47v_hh0E0&feature=share

Rhomberg sign pt unable to stand 

Tandem walking 

Pronator drift absent

Rebound phenomenon present

Heel to knee intact

https://youtube.com/watch?v=Nr1Z4nwTpPk&feature=share

Gait unable to stand

 Meningial sign 

 Kernigs sign negative 

Brudzinski sign negative 

 

Cvs-s1 s2 heard ,no murmur

Respiratory system 

I: Chest bilaterally symmetrical, all quadrants

moves equally with respiration

P: Trachea central, chest expansion normal

P: Resonant

A: B/l equal air entry

B/I VBS

no added sound

Per. Abdominal examination 

I normal

P soft non tender

No organomegaly

P no fluid thrill and shifting dullness

Auscultation:

Investigation 

Ecg

Usg

Mri

Provisional diagnosis

Acute ischemic stroke with infract in right cerebellar hemisphere 

Treatment

Tab .Clopidogrel

 Tab. Cospirin

Tab .atorvastatin

1/07/22

Giddiness was reduced  but he unable  to stand 

He is speaking fluently

And still under medication 

2/07/22

Pain on right side of face reduced

 He is feeling difficultly in speaking 

3/07/22 ,4/7/22

Slurring of speech,pain in abdomen present.

5/7/22

Giddiness is reduced

Slurring of speech reduced.

6/7/22

Bp 150/110mm Hg

Increase in slurring of speech 

7/7/22

Slurring of speech reduced

Pain over limbs abdomen,side of the face reduced

He has discharged