This is a case of a 58 year old male patient,a daily wage worker by occupation
This is a case of a 58 year old male patient,a daily wage worker by occupation
10 years ago
While working, he got injured by an Iron rake on his left leg.
He neglected it for a few days. It got infected for which he was taken to hospital. It was treated and skin graft was placed.
He was then diagnosed to be having Diabetes mellitus and has been on medication ever since.
6 years ago
He and his wife were on a bike and met with an accident when he responded to her when she asked him to divert the bike away from the vehicle coming in front but didn’t do so.
There was no loss of consciousness then but the wife complained that sometimes he went right in front of the vehicle while crossing the road.
5 years ago
He stopped going to work. When asked the reason the wife said that he told her that he didn’t feel like working anymore.
2017 After few days,
1)He started having problem in remembering things such as where he kept his medicines, dress etc. The relatives also mentioned that he stopped communicating with them normally the way he does and talked only when he got anger or frustrated.
2)He was also an alcoholic (drinking a quarter twice or thrice in a week).
It was for these two reasons, the patient was brought to the hospital for consultation.
He was prescribed to use some medication which he failed to use
2019
The patient was brought again to the hospital because of the same complaints
He failed to use the prescribed medication again
He was also diagnosed to be HBV positive
He was advised not to defecate outside which he does till date even though he has a inbuilt lavatory facilities at home
JAN 30 2022
The patient felt fine after getting up
He went out for defecation
While coming back the patient complained that he was
1) Unable to hold the mug with his left hand
2) Dragging his left leg
3) Deviation of mouth towards right side
4) Slurring of speech
He was taken to hospital-1 and CT was taken.
He was shifted to present hospital due to lack of money.
1 FEB 2022
The patient has better functioning of left limbs now
Slurring reduced
No Deviation of mouth observed
General examination:
he is conscious, coherent, cooperative, well oriented to time, place and person. he is moderately built and moderately nourished.
Pallor- absent
Icterus- absent
Cyanosis- absent
Clubbing- absent
Lymphadenopathy- absent
Edema- absent
Vitals on admission-
Temperature - 97.2 F
PR- 64 bpm
BP- 110/70 mm Hg
RR- 20cpm
SpO2- 99% on RA
GRBS-104
Dementia Scoring
Systemic examination:
CVS- S1,S2 sounds heard. No murmurs.
RS- BAE present, trachea is central, no wheeze.
P/A- Soft, non tender, Bowel sounds heard
CNS- GCS 15/15
Power right 5/5 in upper and lower limb
Left 0/5 in upper limb and lower limb
Tone decreased on left upper and lower limb
Reflexes -rt-2+ and lt side- 3+
Rt side -plantar- flexion
Lt side -plantar-withdrawal
Deviation of mouth to right side
PROVISIONAL DIAGNOSIS:
Left hemiplegia with UMN facial palsy secondary to acute infarct in MCA territory
INVESTIGATIONS
TREATMENT :
- INJ. OPTINEURON 1 amp in 100ml NS/IV/OD
- INJ. PAN 40 mg IV/OD
- INJ ZOFER 4 mg IV SOS
- TAB ECOSPIRIN 75mg po/OD
- TAB CLOPIDOGREL 75mg Po/OD
- TAB ATORVAS 20mg PO/OD
- physiotherapy of left upper limb and left lower limb
- ryles feeding
- monitor vitals 4th hrly
- GRBS 6 th hrly
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