60 yr old male with stroke

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 


Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 

A 60year old male patient Presented to casualty(29-06-22)with the chief complaint of giddiness and weakness in both lower limbs since afternoon.              


HOPI:

Patient was apparently asymptomatic 1day back then he developed headache and dizziness for 30min on and off in the early morning but still he went to perform his daily work activities (i.e.agriculture) from the afternoon then he had a deviation of mouth towards right side with giddiness and weakness in both lower limbs.
 He also have pain in the right side of the face
H/o of vomiting(3episodes) which non bilious and non projectile since morning 

From today morning there is difficulty in walking i.e swaying on right side
 h/o slurred speech, no h/ourinary incontinence,
No h/o loss of consciousness (to rule out brainstem involvement)
No h/o transient loss of vision (to rule out TIA)
no h/o fever, night sweats, weight loss
No h/o head /spine trauma
No h/o involuntary movement
No h/o palpitations and sob 
No h/o double vision (3,4,6 cranial nerve)
No h/o tinitus(8th cranial nerve)
No h/o difficultly in swallowing ,nasal regurgitation,hoarness of voice (9,10)
No h/o altered sensorium and behaviour changes
Daily routine 
The patient wakes up at around 4 am and completes his daily morning activities. He is farmer by occupation At around 9:00am he goes back to work and come back home at around 6 pm. He has food and sleeps by 9 pm.

Past history:
H/o hypertension from the past 4years
No h/o diabetes, asthma,tb, epilepsy
No similar complaint in the past


Drug history:
He take anti -HTN drug only when he feels anxiety and weakness in the limbs

Family history:no similar complaint in the family

Personal history

Diet:mixed
Appetite: normal 
Bowel and bladder: regular 
Sleep: reduced
Addiction: occasionally he drinks Alcohol

Examination

General examination 

No pallor, icterus, clubbing, lymphadenopathy ,edema

Vitals

BP:150/100(lft arm)
PULSE RATE:82/min
RESPIRATORY RATE:20cycles/min
TEMPARATURE:afebrile


CNS EXAMINATION
Right handed person 

HIGHER MENTAL FUNCTION
Counsious ,oreinted to time place person
Speech normal
Behaviour normal
Memory intact 
Intelligence normal 
Lobar function normal
CRANIAL NERVE EXAMINATION
  -OLFACTORY-normal
 - optic : normal visual field on the right side 
Left side slight reduced vision from childhood due to trauma


 - oculomotor,trochlear,abducens-intact
Facial nerve unable to smile
 - vestibulocochlear- intact
 - glossopharyngeal -intact
  - vagus-intact
  -accesory spinal ganglion nerve intact
  - hypoglossal intact


Sensory system:
-fine touch: intact
-pain: normal 
-temperature - normal
- vibration -normal
-stereognosis-
-two point discrimination-present


Motor system examination

Nutrition -

U/L. R. L
            Normal. Normal
L/L. Normal. Normal
ANY ATOPHY-

TONE:
        U/L. R. L.
   
                      Hypotonia. Normotonia
         L/L 
                      Normotonia. Normotonia 
    
  

POWER. RIGHT. LEFT.
SHOULDER

 flexion  :               5/5    5/5

 Extension        5/5.  5/5

Abduction     5/5.  5/5

Adduction         5/5.    5/5

Internal rotation 5/5.   5/5

External rotation    5/5.   5/5

Elbow:5/5.    5/5

Flexion.     5/5.   5/5

Extension:5/5.   5/5

Wrist:5/5.  5/5

Flexion:5/5.   5/5

Extension:5/5.   5/5

Abduction : 5/5.   5/5

adduction:5/5.   5/5


Hip

Flexion:5/5.    5/5 

Extension.  5/5.   5/5

Abduction:5/5.   5/5

Adduction 5/5.    5/5

Internal rotation:5/5.    5/5

External rotation.  5/5.    5/5



Knee 5/5.     5/5

Flexion 5/5.    5/5

Extension.   5/5.   5/5 

Ankle.  5/5.     5/5

Plantarflexion:.   5 /5.    5/5

Dorsiflexion.     5/5.  5/5

Toe.   5/5 5/5

Movements:5/5



REFLEXES: 

Corneal present 

Conjunctival  present 

Abdominal: present 

Plantar: present 

DEEP REFLEXES:

Biceps : 5+.   5+
Triceps 5+.   5+
Knee : 5+.      5+
Ankle: 5+.   5+


CEREBELLAR 

NYSTAGMUS absent
DYSADEADOCHOKINESIA absent 
FINGER NOSE tip- unable to perform
Rhomberg sign pt unable to stand 
Tandem walking 
Pronator drift absent
Rebound phenomenon present
Heel to knee intact

Gait unable to stand

 Meningial sign 
 Kernigs sign negative 
Brudzinski sign negative 
 
Cvs-s1 s2 heard ,no murmur
Respiratory system 
I: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
P: Trachea central, chest expansion normal
P: Resonant
A: B/l equal air entry
B/I VBS
no added sound
Per. Abdominal examination 
I normal
P soft non tender
No organomegaly
P no fluid thrill and shifting dullness
Auscultation:
MRI
USG;
MRI
OTHER INVESTIGATIONS
ECG

Provisional diagnosis
Acute ischemic stroke with infract in right cerebellar hemisphere .


Treatment

Tab .Clopidogrel
 Tab. Cospirin
Tab .atorvastatin



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