A 90yr old patient who was a farmer by occupation resident of chityal was brought to casualty with chief  complaints of deviation of mouth to right since yesterday(16/02/22) morning, slurring of speech (16/02/22).



HOPI: 

Patient who was a farmer by occupation (staying at home since 10-15yr)  was apparently asymptomatic 1 yr back,then he developed nocturia which was10-12 times   overnight for which he went to local hospital and diagnosed with type 2 diabetes mellitus and since then he is on regular medication .Yesterday(16/02/22) when he woke up from sleep he   complains of deviation of mouth to right side and slurring of speech.
No c/o involuntary micturition/defecation,involuntary movement, dysphagia 
No c/o UL/LL weakness noted,fever,cold,cough,burning micturition,sob, orthopnea.

Past history:

k/c/o diabetes since 1 year and on regular medication since then.
Not a k/c/o Htn/cad/Tb/bronchial asthma 
No past surgical history


Treat ment  history :On tab metformin 500 mg for diabetes since 1 year 




Personal history: 

Married
Previously farmer
Appetite: Normal
Bowel and Bladder movements: Regular
 
Addictions: 
Alcohol consumption (Occasional -90ml)
Had habit of smoking but stopped 5yrs ago
No other addictions 

Family history : Not significant 

o/e: 

Pt is c/c/c ,well oriented to time,place, person. 

Pallor +



No signs of icterus, clubbing, cyanosis, lymphadenopathy, pedal edema 



Vitals:  

Temp: Afebrile 

Pr: 62bpm 

Rr:17cpm 

Bp:160/90 mmhg 

Spo2: 97% on ra 

Grbs:129mg%


Systemic Examination: 

Cvs:S1S2 heard, no murmurs heard 

Rs: BAE+ ,NVBS heard 

P/A: Soft, nontender



CNS: 

pt conscious with Slurred speech 

No signs of meningeal irritation  

                           left            right 

1) Tone.   UL.   normal.     normal 

                 LL.     normal    normal


2) Power    UL          5/5               5/5 

                    LL           5/5             5/5


3) Hand grip.   100%


4)Reflexes 

       a) Biceps.              +                   + 

       b) Triceps             +                    +  

       c) Supinator.         +                    + 

       d) Knee.                 +                  +                  

       e)Ankle.                 -                    - 

        f) Plantar.           Mute         Mute


5)  Cerebral signs: 

Finger nose coordination: - 

Knee heel coordination: - 


Plan:  

1)tab ecosprin 75 mg po/od  

2)tab  atorvas 20 mg po/od  

3)inj optineuron 1 amp in 100 ml Ns IV/od  

4) physiotherapy 


Investigations: 

Hemogaram:(16/2/22) 

Hb-11.1 

Tlc-4,600 

Pcv-31.9 

Plt-1.81 

Bgt- B positive  

Blood urea-30 

Utica acid-4.4 

Serum creatinine-1.2 

Sodium-139 

Potassium-3.5 

Chloride-97 

Tb -1.2 

Db-0.4 

Sgot-37 

Sgpt-10 

Alkaline phosphate-98 

Tp -6.2 

Albumin-4.0 

A/G-1.86.  

X ray

 ECG


Carotid doppler(17/02/22):


2D ECHO:- 

Imp:- 

-Trivial TR+ ; no MR/AR 

-No RWMA/No MS/AS ; sclerotic AV 

-Good LV systolic function 

-Diastolic dysfunction + ; No PAH/PE


MRI brain (16/2/22):- 

Imp:- 

-Acute Lacunar infarct in right corona radiata 

-Old Lacunar infarcts in left thalamus and left corona radiata 

-Chronic small vessel ischaemic changes



Diagnasis: 

Acute  ischemic CVA with UMN type of left facial palsy with  acute infarct in right corona radiata 


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