GENERAL MEDICINE CASES

45 YEAR OLD WITH RIGHT HEMIPLEGIA 

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A 45 YEAR OLD MALE WAS BROUGHT WITH C/O RIGHT UPPER LIMB AND RIGHT LOWER LIMB WEAKNESS SINCE 2 HOURS (AT 1 AM, 23/12/21) WITH DEVIATION OF MOUTH TO LEFT, LOSS OF SPEECH (+)

HOPI:

PATIENT CAME WITH 

C/O RIGHT UPPER AND LOWER LIMB WEAKNESS, SUDDEN IN ONSET, NON PROGRESSIVE SINCE 2 HOURS

DEVIATION OF MOUTH TO LEFT SINCE 2 HOURS

LOSS OF SPEECH SINCE 2 HOURS

NO C/O SEIZURES, FEVER, ALTERED SENSORIUM, HEAD INJURY

N/K/C/O DM,HTN

O/E

No cyanosis , icterus, clubbing , lymphadenopathy.

Temperature - 97.5°F

PR - 92/ min

RR - 18cpm

BP - 150/90 mmhg

Spo2 - 99% at RA

Grbs - 128mg/dl

CVS :- S1 , S2 heard

RS - BAE present

P/A - soft and non tender

CNS -

PATIENT IS CONSCIOUS, OBEYING COMMANDS, 

UNABLE TO SPEAK 

TONE-

                        R                       L

UL:           DECREASED      NORMAL

LL:           DECREASED      NORMAL

POWER-

                         R                      L

UL:                  0/5                  5/5

LL:                   4/5                 5/5

RELEXES-

                         R                       L

BICEPS            3+                    2+

TRICEPS          2+                     -

SUPINATOR     -                        -

KNEE                3+                    3+

ANKLE             3+                      -

PLANTAR        EXTENSION   FLEXION 

CEREBRAL SIGNS-

FINGER-NOSE- COORDINATION: ABSENT 

KNEE- HEEL- COORDINATION: ABSENT 

PROVISIONAL DIAGNOSIS:

ACUTE INFRACT IN LEFT FRONTAL LOBE, LEFT INSULAR CORTEX

LEFT ICA OCCLUSION

INVESTIGATIONS:

TREATMENT :

1.TAB.ECOSPIRIN 150 MG PO/STAT

    TAB.CLOPITAB 150 MG PO/STAT

    TAB.ATORVAS 80 MG PO/STAT

2. TAB.ECOSPIRIN 150 MG PO/OD

3. TAB.CLOPITAB 75 MG PO/OD

4. TAB.ATORVAS 80 MG PO/ H/S

5. INJ.OPTINUERON 1AMP IN 100ML NS OD

6. BP/PR MONITORING 2nd HOURLY 

7. GRBS MONITORING 12th HOURLY