55 yr old with weakness of left upper and lower limb.

Interns

M Supriya 

Sowmya Kota

Mohitha

Amrutha 

Sanjay

Dr Durga Krishna PGY1

Dr Ajith Kumar PGY2

Dr Laxma Reddy PGY3

Dr Manasa PGY3

Dr Vijayalaxmi (Ast prof.)

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A 55 yr old female presented with weakness of the left upper limb and left lower limb from 1 week.

C/o slurring of speech from 1 week

Deviation of mouth to the right side from 1 week

C/o reduced sleep, reduced appetite, self talking from 2 months

H/o wandering episodes from 1 and half month.

Patient was apparently asymptomatic 22 yr back then she started going out and sitting alone and had wandering episodes. She was taken to a psychiatrist where she was diagnosed with psychosis(NOS) and she was on medication from then and was visiting the psychiatrist and was normal for about 20 yrs and since lockdown she was not using any medication.

Patient has reduced sleep, reduced appetite, self talking from 2 months.

She had 2 wandering episodes 1 and half month back.Patient used to come back home on her own sometimes and sometimes her relatives had to look for her and bring her back.

Patient has only liquid diet from 15 days. 

She is unable to hold water in her mouth and it drips from her mouth when she tries to drink.

She has weakness of left upper limb and lower limb from 1 week, slurring of speech from 1 week and deviation of mouth to right side and patient was referred to kims for further evaluation.

PAST HISTORY:

No h/o HTN, DM, TB, Asthma,Epilepsy.

K/c/o psychosis NOS from 22 yrs and on regular medication except for the last 2 months 

PERSONAL HISTORY:

Patient has a reduced appetite, vegetarian diet, reduced sleep, regular bowel and bladder movements, no addictions

No known allergies.

O/E- 

Patient is in altered sensorium at admission.

No pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy.

Edema present in the left upper and lower limbs.

VITALS

Bp-120/80mmhg

Pr-90bpm

Rr-20cpm

Spo2-98%

Grbs-141

SYSTEMIC EXAMINATION:

CVS- S1S2 +

          No murmurs

RS-BAE+ 

       NVBS+

P/A- soft,non tender, 

         no organomegaly.

CNS- 

Conscious

Slurred speech

Pupils bilateral NSRL

No meningeal signs

Cranial nerves: 

Facial nerve- 

Forehead wrinkles present.

Mouth deviated to right side. 

Loss of nasolabial fold on left side.

Motor system- 

                   Right.               Left

Tone - UL  Hypertonic       Hypotonic

           LL  Hypertonic      Hypotonic

Power-  U/L-  3/5.              0/5

               L/L-  3/5.             0/5

DTR- Biceps.    ++        +++

         Triceps.    ++        +++

        Supinator  +           ++

         Knee.       ++         +++

        Ankle.       +            ++

        Plantar- Flexion   Flexion

Sensory system- intact in both sides.

Cerebellar system- unable to examine.

INVESTIGATIONS:

PSYCHIATRIST OPINION: 

 

OPHTHALMOLOGY OPINION:

NEPHROLOGIST OPINION:

DIAGNOSIS:

CVA with left sided hemiplegia with left LMN type facial palsy with psychosis Nos.

Acute infarct in the left temporal, frontal, right centrum semiovale.

TREATMENT:

1. Ryle’s tube feeding with 100ml milk and 100 ml water  2nd hrly.

2. Tab Aspirin 75mgRT/OD.

3.Tab Atorvas 40mg RT/OD/HS.

4. Inj Pan 40mg IV OD

5.Tab Olanzapine  5mg RT/OD

6. Physiotherapy of left upper and lower limb.