62 Year old Female with Paralysis of Left upper and lower limb

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5th Nov

62 YEAR OLD FEMALE Resident of Nakrekal, labourer ( works in field) by occupation 

Chief Complaint:

Left upper and lower limb paralysis since one day

History of Presenting Illness:

Patient was apparently asymmtomatic 1day back, then she had giddiness (morning 4th Nov) after which she was unable to move her left upper arm ( only 45°abduction, flexion) and lower leg. Local RMP was called who told that BP was high and gave antihypertensive drug.

Then she came to hospital with unable to move left upper and lower limb. Tingling sensation present. 

No paresthesia,  slurring of speech, drooling of saliva, fever, vomitting.

Past history: 

No similar episodes in the past. 

Not a known case of diabetes mellitus, asthma, epilepsy, coronary artery disease. 

No surgical or drug history

Personal history:

Mixed diet

Appetite is normal

Bowel and bladder are regular

Sleep is adequate. 

She is alcoholic since childhood, 90 ml daily. 

She is known smoker, 1-2 daily since childhood

No known allergies. 

Family history: 

No similar complaints.

General Examination: 

Patient is examined in a well lit room after obtaining informed consent. She is conscious, coherent and cooperative, well oriented to time, place and person, moderately built and nourished. 

 No Pallor, Icterus, Cyanosis, Clubbing, generalized lymphadenopathy, Edema 

Vitals:

Temp.- Afebrile

BP- 130/70 mmHg

PR- 62 bpm

RR- 17 cpm

Systemic examination

CNS: 

Higher mental functions:

Oriented to time,place,person

Memory :  Immediate,recent, remote intact

Speech: Normal

No delusions or hallucinations

Cranial nerves: 

1- not tested

2- Pupillary reflex present

3,4,6- No restriction of movement of eye

5-normal( muscles of mastication+sensations of face)

7-Normal, wrinking of forehead seen, able to blow up cheeks

8- Normal hearing

Motor examination:

Tone - Decreased in left upper and lower limb

Power-.                     Right    Left

             Upper limb   4/5       2/5

              Lower limb   4/5      3/5

Reflexes :

Biceps: Right++

               Left: absent

Triceps: Right++

               Left: absent

Supinator: Right++

               Left: absent

Knee: Right: ++

           Left: Absent

Ankle: Right: ++

             Left: Absent

Plantar: Right : Flexion of great toe

               Left: Extension

Cerebellum examination:

Able to do finger nose test.

Not able to do  dysdiadokinesia 

Gait: did not walk due to weakness

CVS: 

S1 S2+ no murmurs heard.

Respiratory system:

Bilateral air entry+ ,normal vesicular breath sounds-heard. 

Abdominal: 

Soft, non tender, no distension

No organomegaly

Bowel sounds heard.

Investigations

Diagnosis

Acute Ischemic Stroke - Acute infarct in right occipital lobe,right posteriotemporal lobe and right thalamus- PCA territory 

Treatment

Tab Ecospirin 150mg PO OD

Tab Clopitab 75 mg PO OD

Tan Atorvas 80 mg PO H/S

SOAP NOTES 6TH Nov

S: 

Tingling of left upper limb and left lower limb

O:

Vitals

BP:130/80mmHg

PR:

Cvs:S1 and S2 are heard

CNS 

HMF intact

Oriented to time ,place And person 

Tone 

Decreased in left upper limb and lower limb

Power 

            R. L

UL. 4/5. 0/5

LL. 4/5. 3/5

Reflexes 

       T. B. S K. A

R. ++. ++. +. ++. -

L. - - - - -

Right plantar flexor

Left plantar extensor

No dysdiadokokinesia of left side

A:

Acute infarct in right occipital lobe,right posteriotemporal lobe and right thalamus- PCA territory 

P:

Conservative management and daily Physiotherapy.