70 year old man with left-sided Hemiplegia, CKD stage 4, ? Anemia of chronic disease, , K/C/O old CVA and Hypertension
A 70 year old man, who was a farmer, came with c/o weakness of left upper limb and left lower limb and difficulty in speaking since yesterday.
He stopped working as a farmer 1 year ago and quit smoking and alcohol intake too.
H/o CVA 1 year ago (left UL and LL weakness) for which he used medication for 4 months and stopped
K/C/O HTN since 1 year and is on regular medication: Tab. Telma 20mg OD and Tab. Cilnidipine 10mg OD
K/C/O CKD since 1 year and was started on Tab. Nodosis, Tab. Orofer, and Tab. Vit. D3 which he was using irregularly and then he stopped 2 months ago and started again 20 days back
6 months ago, he was hit by a bull and fractured his shaft of left Femur. He went to a local RMP and got a cast and was walking with the help of a stand ever since.
1 month ago, he attained a left arm fracture for which his attenders took the patient to a local k-pal (RMP) and got casting done. The cast was removed 1 week back and he was able to move his hand but since yesterday he has been having difficulty lifting his left arm.
No H/O LOC, seizures, vomiting, and trauma
No H/O SOB, Fever, cold, and cough
No H/O burning micturition, and loose stools
No H/O involuntary movements
O/E:
The patient is conscious, coherent, and cooperative, oriented to time, place, and person.
Afebrile
Pallor is present
B/L pedal edema, pitting type, extending up to the knee and left leg externally rotated
BP: 140/90 mmHg
PR: 119 bpm
RR: 24 cpm
Spo2: 98% at RA
CVS: S1S2 +, no murmurs
RS: BAE +
P/A: soft, nontender
CNS:
HMF- patient conscious
speech- no response
MMSE- not elicited
Cranial Nerves-
1st nerve not elicited
2nd nerve not elicited
3rd, 4th, and 6th nerves: Rt Lt
Pupil size: N N
DLR/CLR: N N
No ptosis or nystagmus.
5th nerve: Sensory: not elicited
Motor: not elicited
Corneal reflex normal
Conjuctival reflex normal
7th nerve: Motor: nasolabial fold lost on left side
no deviation of mouth
Sensory: corneal and conjunctival reflexes normal
secretomotor moistness of eye and tongue normal
buccal mucosa normal
8th nerve: Rinne's and Weber's not elicited
9th and 10th nerve: Uvula centrally placed
gag not elicited
11th nerve: Trapezieus not elicited
Sternocleidomastoid not elicited
12th nerve: tongue tone normal, no wasting, no fibrillations, no deviation of tongue
MOTOR SYSTEM
Right. Left
Bulk: Normal Normal
Tone: UL: Decreased Normal
LL: Decreased Normal
Power: not elicited
REFLEXES
Superficial reflexes:
Right Left
Corneal P P
Conjunctival P P
Abdominal - -
Plantar flexor flexor
Deep tendon reflexes:
Right. Left
Biceps. Absent Absent
Triceps. Absent Absent
Supinator. Absent Absent
Knee + not elicitable due to fracture
Ankle. Absent Absent
Primitive reflex -absent
Involuntary movements - absent
SENSORY SYSTEM
Not elicited
Pain present in all four limbs
CEREBELLUM
Titubation - absent
Nystagmus- absent
Intentional tremors - absent
Pendular knee jerk - absent
Coordination test not done
MENINGEAL SIGNS
Kernig's sign - negative
Brudzinki's sign - negative
INVESTIGATIONS at admission
HEMOGRAM :
HB: 7.4
Platelets: 1.83 lakhs
TLC: 7,700
- He may be having an acute infarct in the right MCA due to left upper limb and left lower limb hemiplegia.
- He was diagnosed with CKD a year ago
- K/C/O old CVA
- K/C/O Hypertension since 1 year
- The patient has an altered sensorium and is oriented to time, place, but not person.
- Afebrile
- BP: 130/90 mmHg
- PR: 105 bpm
- RR: 20 cpm
- Spo2: 93% at RA
- GRBS: 136 mg/dl
- Pallor is present
- B/L pitting pedal edema is present up to the knee
- left leg is externally rotated
- CVS: S1S2 heard
- RS: BAE present, coarse crepitations are present at the infraclavicular and mammary region
- P/A: soft, bowel sounds are sluggish and patient didn't pass stools since 5 days
- Pupils are reacting to light
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