CVA ?PCA STROKE ,WITH ACUTE INFARCT IN CEREBELLUM

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Here we discuss our individual patient problems through series of inputs from  available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input

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A 57 year old male who is a autodriver,by occupation came with complaints of 

Giddiness since 4 days

Excessive sweating since 4days

Swaying towards right since 4 days.

HOPI: Patient was apparently asymptomatic 5 days ago,and then developed pain and swelling of bilateral lateral malleolus,for which he visited he visited local RMP,for which he received an injection?not known,followed by which ,he developed excessive sweating and giddiness and difficulty to walk ,associated with swaying to right ,for which he went to a local hospital and was advised to get a CT done,and medications were given,and referred here for further management,and while at admission he is consious,coherent and oriented ,and his blood pressure was 170/100mmhg,and giddiness is present.

Diplopia present, for a brief period of 30 minutes.

Horizontal nystagmus,fast beating towards right.

No dysphagia,ptosis,miosis and anhydrosis

No history of hiccups

No history of headache,nausea,vomiting

No history of blurred vision

No deviation of mouth and drooling of saliva

No involuntary moments.

Past history: No similar complaints in the past

Personal history:Mixed diet 

Apetite Normal 

Sleep adequate 

Bowel and Bladder moments regular.

Addictions:  Chronic alcoholic since 20 years, stopped 2 years back

Chronic beedi smoker since 22 years.

Family history:No significant family history 

GENERAL EXAMINATION:

Patient is moderately built and nourished.








NO PALLOR
NO ICTERUS
NO CYANOSIS
NO CLUBBING
NO KOILONYCHIA 
NO LYMPHADEONAPTHY
SYSTEMIC EXAMINATION: VITALS:

Bp:160/80mmHg in left arm in sitting position 

PR:86bpm

RR:16Cpm

BAE present.NVBS Present 

CVS:S1S2 heard

CNS:


HIGHER MENTAL FUNCTIONS:

Oriented to time place and person 

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 equal.

Pupil reactivity to light:present 

Direct and indirect light reflex are present in both eyes.

Oculomotor(III),Trochlear(IV)and Abducens(VI):ocular movements present.Brief period of diplopia,No ptosis,Horizontal Nystagmus Present 

Trigeminal(V): Sensations over the face present.

Corneal reflex:present 

Jaw jerk: Absent.

Muscles of mastication:Normal(No wasting)

Facial nerve(VII): No deviation of mouth

The wrinkles on both sides of forehead are present.

Taste:intact.

Secretions:Normal 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—Normal tone

           lower limb—Normal tone

Left:Upper limb—-Normal tone

        lower limb—-Norma tone.

POWER OF MUSCLE:

Right upper limb: 5/5

(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:5/5

(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: 

Broad based gait

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:5/10 (incorrect)in Right lowerlimb and 5/10 (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: Plantarflexion

Left side: mute

Cerebellar function tests:

Titubation absent

Trunkal ataxia/gait ataxia swaying towards right

No dysarthria,tremors,hypotonia


Coordination tests:

Finger nose test: done by both hands(normal).

No overshooting.

Finger to finger testing:no incordination.

Diadokokinesia: normal with right hand.

Heel knee test: no incordination 

Rhombergs test: swaying towards right with eyes open 

Steriognosis : intact

Autonomic nervous system:
Increased sweating +
No postural hypotension

Meningeal signs:
No neck pain
No spinal and cranial abnormalities 
No carotid bruit

Other systems:

CARDIOVASCULAR SYSTEM:
Apex beat felt at 5th intercostal space just lateral midclavicular line
Heart sounds normal 
No thrills and murmurs

RESPIRATORY SYSTEM:
Chest symmetrical 
Normal vesicular breath sounds 
No crepts,rhonchi,rales
ABDOMEN:
Soft and non tender
No organomegaly
No visible scars and sinuses 

PROVISIONAL DIAGNOSIS:

CVA ?PCA stroke 

INVESTIGATIONS:










FINAL DIAGNOSIS: 










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