PATIENT CAME WITH CHIEF COMPLAINTS OF DEVIATION OF MOUTH TO RIGHT SIDE, WEAKNESS OF LEFT UPPER LIMB AND LOWER LIMB

 Case History and Clinical Findings:

 PATIENT CAME WITH CHIEF COMPLAINTS OF DEVIATION OF MOUTH TO RIGHT SIDE SINCE YESTERDAY NIGHT WEAKNESS OF LEFT UPPER LIMB AND LOWER LIMB SINCE MORNING 

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY NIGHT THEN DEVIATION OF MOUTH TO RIGHT SIDE AND TODAY MORNING PATIENT HAD DIFFICULTY IN WALKING DUE TO WHICH THEY VISITED A LOCAL HOSPITAL AND WAS TREATED CONSERVATIVELY AND SYMPTOMS DIDNT SUBSIDE AND WEAKNESS PROGRESSED AND WAS UNABLE TO WALK. NO H/O SLURING OF SPEECH, DROOLING OF SALIVA.

NO H/O OF LOSS OF CONSCIOUSNESS,NYSTAGMUS.

NO H/O OF HEAD TRAUMA. 

H/O OF FEVER,LOW GRADE SINCE TWO DAYS NOT ASSOCIATED COUGH, HEADACHE AND VOMITINGS .

H/O OF ALCOHOL CONSUMPTION SINCE 15 YEARS (LAST BINGE YESTERDAY NIGHT)

PAST HISTORY:-

K/C/O TYPE 2 DM SINCE 10 YEARS (ON GLIMI-M2 TWICE DAILY ) NOT K/C/O HTN,CAD,CVA,THYROID DISORDERS,EPILEPSY,ASTHMA. 

PERSONAL HISTORY :

APPETITE NORMAL  

MIXED DIET 

SLEEP ADEQUATE 

BOWEL AND BLADDER MOVEMENTS- REGULAR 

ADDICTIONS: CONSUMPTION OF ALCOHOL 180 ML PER DAY 

GENERAL EXAMINATION :

PATIENT IS CONSCIOUS,COHERENT AND CO-OPERATIVE. 

NO PALLOR, ICTERUS,CYANOSIS,CLUBBING,ICTERUS,LYMPHADENOPATHY, EDEMA

VITALS :

TEMP.- 98.6F 

PR-82BPM 

RR-20CPM

BP-140/80 MMHG 

SPO2-98% AT RA 

SYSTEMIC EXAMINATION: 

CVS-S1S2 HEARD,NO MURMURS 

RS- BAE +,NVBS HEARD 

PER ABDOMEN- SOFT,NON TENDER

 CNS- PUPIL-BILATERAL NSRL 

TONE -R L UL N HYPO LL N HYPO POWER - R L UL 4/5 4/5 LL 0/5 0/5

 REFLEXES- B T S K A P R +2 +2 +1 +2 +1 FLEXION L +3 +3 +2 +3 +2 EXTENSION 30/05/2023 

REFERRED TO PSYCHIATRY DEPARTMENT :-

I/V/O ALCOHOL DEPENDENCE IMPRESSION : TOBACCO DEPENDENCE SYNDROME, ALCOHOL HARMFUL

USE TREATMENT: TAB LORAZEPAM 2MG THAMINE SUPPLEMENTATION

provisional Diagnosis:-

LEFT HEMIPARESIS SECONDARY TO INFARCT IN RIGHT MCA TERRITORY- FRONTO PARIETAL OPERCULUS PARIETO OCCIPITAL REGION, INSULAR CORTEX ADJACENT CORONA WITH K/C/O TYPE II DM SINCE 10 YEARS, DENOVO HTN

 Investigation:-

 USG IMPRESSION: GRADE 2 FATTY LIVER MRI IMPRESSION : AREA OF RESTRICTED DIFFUSION IN RIGHT FRONTAL,PARIETAL, AND OCCIPITAL LOBES WITH LOW SIGNAL OF ADC AND FLARE HYPERTENSIVE SIGNAL -S/O ACUTE INFARCT FEW FOCI OF BLOOMING HYPODENSITY ON SWI IMAGES IN RIGHT FRONTAL LOBE- S/O HEMORRHAGE OR CALCIFICATIONS.

 Treatment Given:-

 1- PLENTY OF ORAL FLUIDS 

2-TAB BENZOTHIAMINE 100MG PO/BD 

3-TAB AMLODIPINE 10MG PO/BD 

4-TAB ECOSPRIN-AV (75/10) PO/HS

 5-TAB GLIMI M1 PO/OB 

6-TAB DOLO 650MG PO/SOS

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