CVA With Right hemiparesis with bilateral knee osteoarthritis .

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A 76year old male patient who is daily wage labourer by occupation came with complaints of 

* Right upperlimb and lower limb weakness since 20/05/2022(morning around 8am)

*Slurring of speech since 20/05/2022 morning 

*Deviation of mouth to left since 20/05/2022 afternoon.

HOPI:

Patient was apparantly assymptomatic 10 years back,later which he developed progressive gradually increasing bilateral knee joint pains,on and off ,for which he used to take injection of painkillers later which pain used to get subsided.Then 3 years back he developed gradual diminision of vision of both eyes and then ?cataract surgery was done for right eye and later after 6 months done for left eye.After that 1 year back ,had a complaint of right sided swelling in the inguinal region for which he was operated and on inspection scar of approximately 6cms was seen.Now again he was assymptomatic till 8am on 20/05/2022,later which he was unable to get up from sleeping position and so he took support of his son for going to washroom (for which his son thought as having knee joint pains which used to be present)and also associated with slurring of speech,and deviation of mouth to left side(identified by attenders around 12pm in the afternoon) and there is drooling of saliva and food is present during food intake.And patient came to casuality around 4:30pm on 21/05/2022, with complaints of right upper limb and lower limb weakness and slurred speech and deviation of mouth to left side.

PAST HISTORY:

No similar complaints in the past.

Not a known case of diabetes and hypertension.

Not a known case of hypothyroidism,TB,Epilepsy.

PERSONAL HISTORY:

No alcohol and smoking history.

Diet:Mixed

Sleep:Adequate

Apetite:Normal

GENERAL EXAMINATION:

Patient is well oriented to time,place and person at the time of admission.

No pallor,icterus,cyanosis,clubbing,koilonychia,lymphadenopathy and edema.











VITALS AT ADMISSION:

Bp:130/80mm of Hg

PR:86bpm

RR:16cpm

CVS:S1 and S2 present 

SYSTEMATIC EXAMINATION:

RS:Bilateral air entry present.NVBS+

CNS:

HIGHER MENTAL FUNCTIONS:

Immediate memory:Intact

Short term memory:Intact

Longterm memory:Intact

No delusions and hallucinations.

CRANIAL NERVES:

Olfactory nerve(I): Smell is intact 

Optic nerve(II):size of both pupils unequal.

Pupil reactivity to light:present (sluggish)

Direct and indirect light reflex are present in both eyes.

Oculomotor(III),Trochlear(IV)and Abducens(VI):ocular movements present.No diplopia,No ptosis,No nystagmus.

Trigeminal(V): Sensations over the face present.

Corneal reflex:present 

Jaw jerk: Absent.

Muscles of mastication:Normal(No wasting)

Facial nerve(VII): Deviation of mouth to left(Increased during smiling)

The wrinkles on both sides of forehead are present.

Taste:intact.

Secretions:Normal/increased in eyes.

Vestibulocochlear nerve(VIII):Hearing intact.

No positional vertigo and nystagmus.

Glossipharyngeal (IX) and Vagus(X): uvula is centre and pilatoglossus pillars are normal and gag reflex intact.

Taste sensations from posterior tongue is normal.

Spinal accesory(XI):Trapezius and Sternocleidomastoid normal.

Hypoglossal(XII): Tongue (opening )central in postion.

No weakness  and wasting of tongue.

Tongue moments normal.

MOTOR SYSTEM:

No visible muscle wasting is seen on inspection.

TONE OF THE MUSCLE:

Right: upper limb—-Hypotonia(decreased tone)

           lower limb—-Hypotonia(decreased tone)

Left:Upper limb—-Normal tone

        lower limb—-Norma tone.

POWER OF MUSCLE:

Right upper limb: 2/5

(Tested for supraspinatus,Deltoid,infraspinatus,Rhomboid,pectoralis major,latissimus dorsi,biceps, brachioradialus, triceps,Extensor carpi radialis, Extensor carpi ulnaris,Extensor digitorum,Flexor carpi radialis and Flexor carpi ulnaris,Abductor pollicis longus, Extensor pollicis brevis,Extensor pollicis longus,Lumbricals,Abductor digiti minimi.)

Right lower limb:3/5

(Tested for Quadriceps femoris,Tibialis anterior,Tibialis posterior,Gastrocnemius,peronei,Extensor digitorum longus,flexor digitorum longus,extensor digitorum brevis,extensor hallucis longus)

Left upper limb:5/5

Left lower limb:5/5

POSTURE AND GAIT:Not elicited.

No involuntary movements or tremors are seen.


SENSORY SYSTEM:

Fine touch, crude touch and pain intact in all four limbs.

Temperature: Differentiation of cold and hot objects is seen.

Joint postion:2/10 (incorrect)in Right lowerlimb and 1/10 (incorrect)in left lower limb.

No abnormal sensations are present.

REFLEXES:

Tendon reflexes: 

Jaw jerk: Not seen

Right:

Biceps jerk:+++

Triceps jerk:+++

Supinator jerk:+

Knee jerk:+++

Ankle jerk:+

Left side:

Biceps jerk:++

Supinator jerk:++

Triceps jerk:++

Knee jerk:++

Ankle jerk:++

Superficial reflex: 

Abdominal reflex: present 

Plantar reflex: of right side: Dorsiflexion

Left side:plantar flexion.

Coordination tests:

Finger nose test: done by left hand(normal).

No overshooting.

Finger to finger testing:not elicited.

Diadokokinesia: normal with left hand.

Heel knee test: cant be elicited.




INVESTIGATIONS:























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