57M with altered sensorium

 57 YEAR OLD MALE PATIENT CAME WITH C/O OF SLURRED SPEECH 4PM ON 5/08/2023

C/O RIGHT UPPER LIMB &LOWER LIMB WEAKNESS SINCE 4PM.

PATIENT PRESENTED TO CASUALITY WITH ALTERED SENOSIRUM SINCE 4PM

HOPI: PATIENT HAS A H/O SLURRED SPEECH AND H/O RIGHT UPPER LIMB AND LOWER

LIMB WEAKNESS SINCE THEN ASSOCIATED WITH FALL.

NO LOC, NO ENT BLEED

NO H/O FEVER, BURNING MICTURITION, LOOSE STOOLS

NO H/O SOB, PALPITATIONS, ORTHOPNEA, PND

HISTORY OF PAST ILLNESS:

NOT A K/C/O HTN,DM,EPILEPSY, THYROID DISORDERS.

O/E:

GCS-E5 V4 M5

BP- 90/60MMHG

PR- 68BPM

CVS- S1S2 +

RS- NVBS + SPO2- 97% ON RA

CNS-

TONE: RIGHT LEFT

UL INCREASED INCREASED

LL INCREASED INCREASED

POWER: UL &LL COULDNT ELICIT

REFLEXES: B +++ ++

T + +

S + +

K - +

A - -

P FLEX FLEX

PUPILS- B/L CONSTRICTED, SLUGGISH REACTIVE

COURSE OF ADMISSION:

PATIENT WAS ADMITTED I/V/O ABOVE MENTIONED COMPLAINTS. NECESSARY

INVESTIGATIONS WERE DONE.

MRI FINDINGS- ACUTE INFARCT IN LEFT CAUDATE AND LEFT LENTIFORM NUCLEUS (MCA

TERITORY)

AGE OF INFARCT 16-24HRS

ON CLINICAL EXAMINATIONCNS - TONE: RIGHT LEFT

UL INCREASED INCREASED

LL INCREASED INCREASED

POWER: UL &LL COULDNT ELICIT

RELEXES: B +++ ++

T + +

S + +

K - +

A - -

P FLEX FLEX

PUPILS- B/L CONSTRICTED, SLUGGISH REACTIVE DIAGNOSED AS RIGHT HEMIPARESIS SECONDARY TO ACUTE INFARCT IN LEFT CAUDATE

AND LENTIFORM NUCLEUS (MCA TERITORY) WITH ALTERED SENSORIUM

SECONDARY TO ALCOHOL INTOXICATION.

CNS EXAMINATION ON 11/08/2023

TONE: RIGHT LEFT

UL INCREASED NORMAL

LL INCREASED NORMAL

POWER: UL 3/5 4/5

LL 3/5 4/5

RELEXES: B +++ +++

T ++ ++

S + +

K +++ ++

A ++ -

P EXTENSOR EXTENSOR.

THE PT WAS MANAGED CONSERVATIVELY &WAS DISCHARGED IN A HEMODYNAMICALLY

STABLE CONDITION.

Investigation

HEMOGRAM- HB: 16.8G/DL

TC: 9,700

NEUTROPHILS: 67

LYMPHOCYTES: 18

MCH: 33.8

RDW-CV: 16.0

PLATELET: 2.35 LAKHS/CU.MM

LFTTB: 1.82

DB: 0.52

ALP: 151

TP: 6.0

ALBUMIN: 3.31

A/G RATIO: 1.23

RFT- UREA: 23

CREATININE: 1.3

URIC ACID: 6.9

CALCIUM: 9.8

PHOSPHORUS: 2.2

SODIUM: 131

POTASSIUM: 3.6

CHLORIDE: 99

Diagnosis RIGHT HEMIPARESIS SECONDARY TO ACUTE INFARCT IN LEFT CAUDATE AND LENTIFORM NUCLEUS (MCA TERITORY) WITH ALTERED SENSORIUM SECONDARY TO ALCOHOL INTOXICATION.

Treatment Given(Enter only Generic Name)

ON ADMISSION:

1. IV FLUIDS 2.NS @ 75ML/HR, 1.RL

2. INJ THIAMINE 200MG IN 100ML NS IV/BD

3. TAB CASPRIN 75MG + CLOPIDOGREL 75MG + ATORVOSTAIRIN 10MG

4. PHYSIOTHERAPY FOR TIGHT UPPER AND LOWER LIMBS

5. NICOTINE GUMS PO/BD

Advice at Discharge

1 TAB. THIAMINE 100 MG PO/BD X 7 DAYS

2. NICOTINE GUMS PO/BD X 7 DAYS

3. T. BACLOFEN XL 20 MG PO/OD X 7 DAYS

4. T.ECOSPRIN -GOLD PO/HS

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