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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