A 60yr old male patient with Giddiness

A 60 yr old male came to OPD with the 
Chief complaints :-
Giddiness since 1 day 
HOPI:-
Patient was asymptomatic 6 mnths back then he developed Giddiness with slurred speech.He was taken to a near by hsptl there CT BRAIN was done is showed-
1.SMALL HYPODENSE AREAS IN THE BRAINSTEM , BILATERAL CAPSULOGANGLIONIC REGIONS
  ? OLD VASCULAR INSULT
2.BILATERAL PERIVENTRICULAR WHITE MATTER HYPODENSITIES.
  ? CHRONIC ISCHEMIC CHANGES
3. AGE RELATED ATROPHIC CHANGES.
Patient is a known case of hypertension and Diabetic type-2  1 yr back .
He was on irregular medication ,
He hasn't been taking his Anti hypertensive medication since 2 days .
#TODAY MORNING (14-02-2022)-AFTER WAKING UP FROM HIS BED, THE PATIENT EXPERIENCED GIDDINESS AND ON TRYING TO GET UP FROM HIS BED HE FELL FROM HIS BED FOLLOWING WHICH HE DEVELOPED THE SWELLING OF HIS LIPS.
 HE ALSO NOTICED RIGHT UPPER LIMB AND LOWER LIMB WEAKNESS. 
 HIS WIFE AND SON NOTICED DEVIATION OF MOUTH TO THE LEFT AND THE PATIENT DEVELOPED SLURRED SPEECH FEW MINUTES LATER. 
PAST HISTORY:-
HISTORY OF TRAUMA TO HIS RIGHT SHOULDER (HE ACCIDENTALLY WALKED INTO THE WALL) SINCE THEN THE PATIENT HAS BEEN COMPLAINING OF PAIN OF LIFTING HIS RIGHT ARM.
GENERAL EXAMINATION:-
THE PATIENT WAS CONSCIOUS, COHERENT, COOPERATIVE WITH A GCS OF 15/15
HOWEVER HE HAD SLURRED SPEECH, WITH INTACT COMPREHENSION AND REPETITION.
VITALS:-
 BP -160/110MMHG
PR - 118 BPM
SPO2 - 99 % @ RA
RR -16 CPM
GRBS - 154MG/DL
NEUROLOGICAL EXAMINATION:

HMF INTACT 

SPEECH - SLURRED WITH INTACT COMPREHENSION AND REPETITION 

CNS EXAMINATION-


TONE - REDUCED IN RIGHT UPPER LIMB

POWER:

                                RIGHT     LEFT 

UPPER LIMB.              4+.         5

LOWER LIMB              4+.          5
REFLEXES:

BICEPS.                      3+.           3+

TRICEPS                     3+            3+

SUPINATOR.               3+           3+

KNEE.                          3+.           3+
 
ANKLE.                       2+.            1+

SENSORY SYSTEM - INTACT .
CRANIAL NERVES:

*LOSS OF NASOLABIAL FOLD ON THE RIGHT SIDE.
*DEVIATION OF MOUTH TO THE LEFT SIDE. 
*DROOLING OF SALIVA ON THE RIGHT SIDE .
*LOSS OF FRONTAL FOLDS ON THE RIGHT SIDE .
PATIENT IS ABLE TO PERFORM HEEL TO KNEE TEST 
FINGER NOSE TEST
FINGER FINGER TEST 

CVS - S1, S2 PRESENT

LUNGS - CLEAR ON AUSCULTATION 

PER ABDOMEN -
NON TENDER
BOWEL SOUNDS +
INVESTIGATION:-
 MRI BRAIN -WHICH REVELEAD ACUTE LEFT LENTIFORM NUCLEUS INFARCT .
ECG:-
2D ECHO:

MRI BRAIN:-



PROVISIONAL DIAGNOSIS:
RIGHT SIDED CVA,
ACUTE LEFT LENTIFORM NUCLEUS INFARCT : MCA.
TREATMENT :-
1) Head end elevation
2) Tab. Ecosporin 75mg/ po/OD
3) Tab. Atorvas 20mg/ po/Hs
4) Tab. Telma 40mg/po/OD
5) Tab. Zoryl m1/po/OD
6) moniter vitals
7) phsiotherapy of right upper limb and lower limb
8) GRBS charting 6th hrly
9) Inj. Optineuron in 100ml NS/IV/OD.







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