A 30 YR OLD MALE PATIENT WITH WEAKNESS OF RIGHT UPPER LIMB AND LOWERLIMB

MEDICINE CASE DISCUSSION

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MAY 19 ,2021

A 30 YEAR OLD MALE PATIENT WITH WEAKNESS OF RIGHT UPPERLIMB AND LOWERLIMB ,DEVIATION OF MOUTH  TOWARDS  LEFT :

S.SHIVANIREDDY

MBBS 8th SEMESTER

ROLL NO 116

 Under the guidance of  Dr.VINAY(PG)  AND  Dr.VILASITH(INTERN)

I  have been  given this case to solve in an attempt to understand the topic of ''patient clinical data analysis '' to develop my competency in reading and comprehending clinical data including history,clinical findings,investigations and come with a diagnosis and treatment plan.

CASE DISCUSSION

A 30 YEAR OLD  MALE PATIENT LORRY DRIVER BY OCCUPATION CAME TO THE OPD WITH CHIEF COMPLAINTS OF

1. WEAKNESS OF RIGHT UPPERLIMB AND LOWER LIMB SINCE ONE DAY.

2.DEVIATION OF MOUTH TOWARDS LEFT SINCE ONE DAY.


HISTORY OF PRESENTING ILLNESS:

 Patient's brother was in jail since 2 months so that patient was emotionally disturbed about this situation.He went out and asked for money required for the bail for which he went in hot climate for 10-15 days.Patient was occasionally alcoholic who used to drink 500ml ofalcohol (whiskey) once in a week.Patient went to his relative's house(where fall has occured).Previous night before his fall he didn't drink. 

Patient was apparently asymptomatic yesterday morning then he had:

suddenfall without loss of consciousness.

 no complaints of involuntary movements and frothing

 no complaints of involuntary micturition and defecation

 no complaints of headache and blurring of vision

 no complaints of chest pain ,palpitations ,syncopal attacks

no complaints of orthopnea,Shortness of breath and paroxysomal nocturnal dyspnea


HISTORY OF PAST ILLNESS:

Patient had  no  history of similar complaints in the past.Patient had road traffic accident 4 years back then he had posterior dislocation of shoulder,zygomatic and mandibular process.Patient had no history of diabetes, epilepsy,TB,Asthma,Hypertension 

TREATMENT HISTORY:

No significant drug and surgical history

PERSONAL HISTORY :

Diet: Vegetarian

Apetite: Normal

Sleep: Adequate

Bowel and bladder movements:Regular

Addictions:  Ocassional alcoholic(Weekly once-90 to 180ml/day)

Allergies: None

FAMILY HISTORY:

No significant family history.

GENERAL EXAMINATION:

 The patient is conscious,coherent and not cooperative .He is drowsy and disoriented to time,place and person.

No pallor

No icterus

No clubbing

No cynosis

No generalised lymphadenopathy

No bilateral pedal oedema.

SYSTEMIC EXAMINATION:

RESPIRATORY SYSTEM:Normal vesicular breath sounds heard 

CVS:S1 and S2 heard.No added murmers.

PER ABDOMEN:Soft and non tender.No organomegaly.

CNS:

1.The patient is conscious,coherent and not cooperative .He is drowsy and disoriented to time,place and person.Patient shows no signs of meningeal irritation.

2.GCS :E4V4M6-14/15

3.REFLEXES : LEFTSIDE-Withdrawl reflex.

                      :RIGHTSIDE -Extensor reflex

4.PUPILS:

RIGHT :Dilated -Non reactory to light

LEFT  : Normal- Reactory to light


LOCAL EXAMINATION:  No External injuries or scars are seen.


INVESTIGATIONS:

1.HEMOGRAM





2.LIPID PROFILE




3.RANDOM BLOOD SUGAR:




4.LIVER FUNCTION TESTS:




5.RENAL FUNCTION TESTS:                                                                                                 



6.APTT TEST:




7.PROTHROMBIN TIME:




8.COLOUR DOPPLER  2D  ECHO:



9.ECG




10.MRI SCAN:




 














 



CLINICAL IMAGES








PROVISIONAL DIAGNOSIS:

RIGHT SIDED CEREBROVASCULAR ACCIDENT WITH ACUTE INFARCT IN LEFT INTERNAL CAPSULE ,CAUDATE NUCLEUS,
PUTAMEN,LEFT THALAMUS,LEFT INSULAR LOBE,PRECENTRAL GYRUS(ACUTE INFARCT IN LEFT MCA TERRITORY)


TREATMENT:

1.Injection Mannitol 100ml/IV/TD 

2.TAB Ecospirin 75 mg po/OD

3.TAB ATORVAS 40mg po/HS

4.BP/PR/TEMP/SP02 MONITORING (4th hourly)

5.RT FEEDS-100ml milk with protein powder(2nd hourly)




THANK YOU  Dr.VINAY SIR ,Dr.VILASITH SIR FOR THE GUIDANCE .
THANK YOU Dr.BISWAS SIR FOR THE OPPORTUNITY.

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