final practical examination : long case
Final practical examination : long case
A 53 year's old female with complaints of altered sensorium, weakness of right upper limb and lower limb
Amit sharma
HT. No. 1701006007
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A 53 year old female came with altered sensorium ,difficulty in walking ,loss of speech ,weakness of right upper limb and right lower limb.
HOPI :
Patient was A known Case of Diabetes Since 11 Years and Hypertensive since 1 Year.
She developed Giddiness which later Resolved on the Next Day.
RMP was called on and He prescribed Cinarizine and He also found that her BP was around 280 mmHg and gave Anti Hypertensive Drug(Telmisartan).
On the next Day While she was going to washroom was unable to lift her leg and she was dragging her leg which was noticed by daughters so was brought to our Hospital .On her Way to Hospital She Couldn’t recognise her Daughters.
On Examination She Had Altered Sensorium ,Difficulty in Speaking,Weakness in Upper Limb And Lower Limb.
Daily Routine : She used To wake up At
5: 30 am and would complete her Daily House Old Activities.
Negative History : No History of Headache,Fever,Vomiting ,Chest Pain,Palpitations and Shortness of Breadth.
Treatment History : For Diabetes - Metformin 500mg
For Hypertension :
Telma 40mg
Cilindipine 10mg
Metoprolol 50mg
Personal History:
Diet Mixed
Appetite Normal,
Bowel And Bladder Regular.
Sleep Adequate
No Allergies And Addictions.
Family History not Significant
General Examination:
Patient is Conscious, but not Cooperative and is oriented to Place and Person.
Moderately Built and Nourished.
Pallor :Absent
Icterus: Absent
Clubbing: Absent
Cyanosis :Absent
Lymphadenopathy :Absent
Edema:Absent
Vitals :
Temperature - 100.8
Pulse 90 bpm
B.P 180/80mmHg
SpO2 94%.
SYSTEMIC EXAMINATION :
CVS : S1 S2 heard, no murmurs
RS : Bilateral air entry present, normal vesicular breath sounds, no added sounds
GIT : Soft, non-tender, no organomegaly
CNS :
Dominance - Right handed
Higher mental functions
• conscious
• oriented to person and place
• memory - able to recognize their family members
• Speech - Broca's aphasia ( only comprehension, no fluency, no repitition)
Cranial nerve examination
• 1 - couldn't be elicited
• 2- Direct and indirect light reflex present
• 3,4,6 - no ptosis Or nystagmus
• 5- corneal reflex present
• 7- no deviation of mouth, forehead wrinkling present
• 8- able to hear
• 9,10- position of uvula couldn't be visualized
• 11- sternocleidomastoid contraction present
• 12- no tongue deviation
Motor system
Attitude - right lower limb externally rotated
Tone - Hypotonia on right side(both UL,LL)
Normal tone on left side(UL,LL)
Bulk - Rt. Lt.
Arm 26cm. 26cm
Forearm 19cm 19cm
Thigh 42 cm. 42cm
Leg 28cm. 28cm
Tricepsreflex
Ankle jerk reflex
Biceps Reflex(Right)
Tricepsreflex
Knee Reflex(left)
Assessment of tone
Left lower limb
Upper limb tone
Ankle jerk reflex
Babinskis positive (rt side)
Babinski (left side)
POWER :
Sensory system : responding to pain
Cerebellar signs : couldn't be elicited
Diagnostic tests:
MRI
ECG
Medication
IV FLUIDS-NS @ 75 ml / hr
-RT. 100ml MILK WITH PROTEIN POWDER 8th hrly
100ml water Every 2nd hrly
-ING.CITICHOLINE800mg /IV/IN 100 ml NS/BD
-ING.PAN40mg/PO/OD
-TAB. ECOSPIRIN 150mg /PO/HS
-TAB.ATORVAS40mg/PO/OD
-TAB.AMLONG 5mg /PO/OD
-ING .HUMAN ACTRAPID INSULIN ACC. TO GRBS CHECK
-TAB . DOLO 650mg SOS if temp>100F
-B.P. MONITORING 4th hrly
