1801006188- SHORT CASE
PAST HISTORY:
No historyof similar complaints in the past.
Known case of Tuberculosis 15 years back-used medication for 6 months
He is a known case of hypertension since 1 year and takes medicines irregularly(Tab.Amlodipine 5mg)
No history of diabetes,asthma,epilepsy.
FAMILY HISTORY:-
His father is a known case of of diabetes, hypertension and tuberculosis and he passed away due to covid.
Both his sisters are known case of diabetes and Hypertension.
Brother had history of stroke 3years ago
GENERAL EXAMINATION:-
patient was consious ,coherent ,cooperative and well oriented to time place and person.
No pallor,no icterus, no cyanosis, no clubbing, no lymphadenopathy,no edema
Vitals-
pulse rate-60 bpm
Respiratory rate- 18 cpm
Blood pressure-130/80mm of hg
Temperature- afebrile
Systemic examination-
Cns-
Higher mental function :-
Consiousness, coherent
Well Oriented to time place and person
Speech-comprehension present,repetation present, no fluency
Memory- immediate,recent and remote present
No delusions or hallucinations
Cranial nerve examination:-
I- Olfactory nerve- sense of smell present
II- Optic nerve-direct and indirect light reflex present
III- Oculomotor nerve, IV- Trochlear and VI- Abducens- direct and consenual light reflex, accomodation reflex present, no diplopia, no nystagmus, no ptosis.
V- Trigeminal nerve- sensory: sensation present over face.
motor-Masseter, temporalis and pterygoid muscles are normal.
Reflex- Corneal reflex, conjunctival reflex and jaw jerk is present.
VII- Facial nerve- face is symmetrical.
Motor-forehead wrinkling present , nasolabial folds prominent on both sides.
Sensory- taste sensation on ant 2/3 of tongue present.
Reflex-corneal and conjunctival reflex present
VIII- Vestibulocochlear nerve- decreased hearing of the left ear ( rinner’s negative for 256 Hz and 512 Hz) and normal hearing of the right ear.
No nystagmus
IX- Glossopharyngeal nerve- palatal movements present and equal.
gag reflex present
X- Vagus- palatal movements present and equal
XI- Accessory nerve- trapezius, sternocleidomastoid contraction present
XII- Hypoglossal nerve- deviation of tongue to right side.
Motor systerm:-
1) Bulk:- right left
-appearnace:- normal normal
-palpation:- normal normal
-measurements:- right Left
Upper limb -(arm):-. 29cm 29cm (fore arm):-. 26cm 25 cm
Lower limb-( thigh) :- 49cm 49 cm
( Leg):- 31 cm 31 cm
2) Tone:-.
Upper limb:- normal normal
Lower limb:- normal normal
3) Power:-
Upper limb:-
Shoulder:- 5/5 5/5
Elbow :- 5/5 5/5
Wrist:- 5/5 5/5
Lower limb-
Hip:- 5/5 5/5
Knee:- 5/5 5/5
Ankle:- 5/5 5/5
Leg:- 5/5 5/5
4) Reflex:-
Biceps reflex:- 2+ 2+
Triceps reflex :- 2+ 2+
Knee reflex:- 2+ 2+
Ankle reflex:- 2+. 2+
SENSORY SYSTEM:-
Crude touch -present
Pain - present
Temperature- present
Fine touch- present
Tactile localisation-present
2 point discrimination-present
CEREBELLAR SYSTEM-
no gait ataxia
Nystagmus-no
Dysarthria-present
Intention tremor-absent
Limb coordination tests:-
Finger nose test, heel shin test are normal.
dysdiadochokinesis
MENINGEAL SIGNS:-
No neck stiffnes,no kernigs and brudzinsky sign.
CVS-
Inspection- chest wall appears normal in shape and symmetrical,no visible pulsations,scars,dilated veins.
PALPATION- apical impulse felt at 5 ICS medial to MCL.
AUSCULATION-s1 s2 heard nor murmurs heard
RESPIRATORY SYSTEM-
Inspection-chest wall normal shape and symmetrical movement with repiration, no dilated veins,no scars
Palpation- trachea central,Chest wall movements symmetrical, tactile vocal fremitus symmetrical.
Percussion- resonant,no pain and tenderness
Ausculation-normal vesicular breath sounds heard ,no addent sounds.
PER ABDOMINAL EXAMINATION:-
Inspection- abdomen round ,umbilicus in center not everted ,no visble sinuses and scar,no visible peristalsis,
Palpation-no pain and tenderness no organomegaly
Auscultation-bowel ssounds heard
Provisional diagnosis:-
Cerebrovascular accident
with acute infarct in left internal capsule
and acute infarct in left occipital lobe
Investigations:-
Complete blood picture
Haemoglobin:11.7
Peripheral smear: normocytic normochromic anemia
Red blood cells:3.86
Pcv:34.6
Platelet count:2.10
Total leucocyte count:5,100
Fasting blood sugar : 92 mg/dl
Serum creatinine :1.3 mg/dl
Blood urea 38 mg/dl
COMPLETE URINE EXAMINATION:-
Colour : pale yellow
Appearance : clear
Reaction :acidic
Albumin:nil
Sugar: nil
Bile salts and bile pigments : nil
RBC : nil
Crystals :nil
Casts : nil
pus cells:2-3
epithelial cells-2-3
SERUM ELECTROLYTES:-
Sodium: 145 mEq/L
Potassium:4.2mEq/L
Chloride:104 mEq/L
Calcium ionized:1.11 mmol/L
Xray chest:-
Fever chart:-
Ecg-
Carotid doppler:-
MRI REPORT:-
MRI IMPRESSION- infarcts in left internal capsule
Provisional diagnosis:-
Cerebrovascular accident With acute infarct in left internal capsule and
acute infarct in left occipital lobe
TREATMENT-
INJ. OPTINEURON 1 AMP IN 500ML
NS IV OD
TAB. CLOPITAB 75 MG PO/OD
TAB. ECOSPRIN AV 75/10 PO
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