A 55 year old male C/c slurring speech deviation of mouth towards left

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 Chief complaints:

A 55 year old male occupation by carpenter came with c/o slurring of speech since 2 days

C/o deviation of mouth towards left side since 2 days

History of present illness :

Patient was apparently alright 2 days back then he had slurring of speech which is sudden in onset and Patient’s wife noticed deviation of mouth towards left side on the same day 

No weakness of upper and lower limb.

No h/o trauma 

No h/o involuntary movenents

No h/o of numbness or paresthesia

No LOC/ altered sensorium.

No h/o altered smell

No h/o blurring of vision

No drooling of sliva

No drooping of eyelids

No difficulty in swallowing

Past history:

K/c/o HTN since 1 year on ATENOLOL and AMLODIPINE 5mg

He is not a k/c/o DM II,  CVA, CAD, ASTMHA

Personal history:

Diet: mixed

Apetite: normal

Sleep: disturbed

Bowl and bladder: regular

Addictions: drank sara when he was 23 years old and stopped when he was 30 years.

Family history:

Father is a known case of Diabetes Hypertension

GENERAL EXAMINATION:

Patient is conscious coherent cooperative 

No pallor, icterus, cyanosis, clubbing, generalised edema or lymphadenopathy

Vitals :

bp-130/80

Pr -90bpm

RR: 18

Spo2 -98% @ RA

Systemic examination:

CNS:

             Higher mental functions   

conscious,coherent and cooperative 

memory- intact 

Speech - comprehension present, no fluency, repetition present

           Cranial nerve examination  

          

I- Olfactory nerve-  sense of smell present

II- Optic nerve- direct and indirect light reflex present 

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis

V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.

VII- Facial nerve- face is symmetrical, forehead wrinkling present , nasolabial folds prominent on both sides.

VIII- Vestibulocochlear nerve- decreased hearing of the left ear ( rinner’s negative for 256 Hz and 512 Hz) and normal hearing of the right ear

IX- Glossopharyngeal nerve-  palatal movements present and equal

 X- Vagus- palatal movements present and equal

XI- Accessory nerve- sternocleidomastoid contraction present

XII- Hypoglossal nerve- deviation of tongue to right side and no fasciculations present

Sensory system examination:

                                   

    Motor system examinations  

    

CVS: S1 & S2 heard. No murmurs 

Respiratory system:Normal vesicular breath sounds heard 

Abdomen: Soft and non-tender.No organomegaly

Investigations:

Complete blood picture

 

Haemoglobin:11.7

Peripheral smear: normocytic normochromic anemia

Red blood cells:3.86

Pcv:34.6

Platelet count:2.10

Total leucocyte count:5,100

Fasting blood sugar : 92 mg/dl

Serum creatinine :1.3 mg/dl

Blood urea  38 mg/dl

CUE:

Colour : pale yellow

Appearance : clear

Reaction :acidic

Albumin:nil

Sugar: nil

Bile salts and bile pigments : nil

RBC : nil

Crystals :nil

Casts : nil

pus cells:2-3

epithelial cells-2-3

Serum electrolytes 

Sodium: 145 mEq/L

Potassium:4.2mEq/L

Chloride:104 mEq/L

Calcium ionized:1.11 mmol/L

ECG: 

MRI : 

Provisional diagnosis:

Cerebrovascular accident 

With acute infarct in left internal capsule

With acute infarct in left occipital lobe

Treatment:

INJ. OPTINEURON 1 AMP IN 500ML

NS IV OD 

TAB. CLOPITAB 75 MG PO/OD

TAB. ECOSPRIN AV 75/10 PO