28/M WITH INABILITY TO WALK,WEAKNESS OF LEFT UL,LL

 

28/M WITH INABILITY TO WALK,WEAKNESS OF LEFT UL,LL

"This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs.This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment"

PATIENT CAME WITH C/O LEFT UPPER LIMB, LOWER LIMB WEAKNESS SINCE 2 DAYS.

SLURRING OF SPEECH SINCE 1 DAY.

HOPI:-

PATINET WAS APPARENTLY ASYMPTOMATIC 2 DAYS BACK THEN, WHILE DRIVING CAR HE HAD SUDDEN ONSET WEAKNESS OF LEFT UPPER AND LOWER LIMBS WITH SLURRING OF SPEECH.

NO H/O INVOLUNTARY MOVEMENTS OF UL & LL, INVOLUNTARY MICTURITION, DEFECATION.NO H/O LOSS OF CONSCIOUSNESS.

8 YEARS BACK,PATIENT HAD 3 EPISODES OF GTCS FOR WHICH HE WAS ADMITTED IN GANDHI HOSPITAL AND WAS DIAGNOSED AS CSVT ( THROMBUS IN TRANSVERSE AND SIGMOID SINUS ) AND WAS KEPT ON WARFARIN WHICH HE USED FOR 1 MONTH AND DISCONTINUED.ALL THESE YEARS,HE DID NOT HAVE ANY SIMILAR COMPLAINTS.

 

PAST HISOTRY:-

NOT A K/C/O DM, HTN,TB,ASTHMA

 

GENERAL EXAMINATION :

PATIENT IS C/C

NO PALLOR,ICTERUS,CLUBBING,CYANOSIS,LYMPHADENOPATHY,PEDAL EDEMA

VITALS : TEMP - AFEBRILE,BP - 140/90 MMHG,PR - 86 BPM,SPO2-99% @ RA

SYSTEMIC EXAMINATION :

CVS : S1S2 HEARD,NO MURMURS

RS : BAE + , NVBS +

P/A : SOFT,NON TENDER

CNS :  LEFT  RIGHT

    TONE

       UL    N     N

       LL    N      N

  POWER

      UL   5/5   4/5

      LL    5/5   4/5

REFLEXES

  BICEPS     +       +

  TRICEPS    +      +

SUPINATOR +       +

  KNEE         +         +

  ANKLE       +         +

  PLANTAR   +        +

PROVISIONAL DIAGNOSIS :

ACUTE CVA WITH LEFT HEMIPARESIS (ACUTE INFARCT IN RIGHT THALAMUS) WITH K/C/O CSVT (THROMBUS IN TRANSVERSE AND SIGMOID SINUS) WITH HYPERHOMOCYSTEINEMIA ( HOMOCYSTEINE > 65 MMOL/L ON 17-01-2021 )



MRI BRAIN PLAIN WITH MR VENOGRAM AND MRI ANGIOGRAM

IMPRESSION :

1.SUB ACUTE INFARCTS IN THE RIGHT THALAMUS,RIGHT CEREBELLAR HEMISPHERE AND RIGHT SUPERIOR CEREBELLAR PEDUNCLE WITH HEMORRHAGIC TRANSFORMATION IN RIGHT SUPERIOR CEREBELLAR INFARCT - LIKELY EMBOLIC INFARCTS

2.LOSS OF NORMAL FLOW VOID SIGNAL IN LEFT TRANSVERSE SINUS AND PROXIMAL PART OF LEFT SIGMOID SINUS WITH FEW SURROUNDING COLLATERALS - S/O CHRONIC THROMBUS.

3.NORMAL MR ANGIOGRAM STUDY

 


CAROTID ARTERY DOPPLER : 

NO ABNORMALITY DETECTED

 


2D ECHO :

EF - 60 %

NO MR/AR/TR

NO RWMA,NO AS/MS

GOOD LV SYSTOLIC FUNCTION

NO DIASTOLIC DYSFUNCTION,NO PAH/PE

 


FASTING LIPID PROFILE :

CHOLESTEROL : 139

TGL : 100

HDL : 39

LDL : 92

VCDL : 20



PLAN : 


1.TAB ECOSPIRIN 150 MG PO/OD

2.TAB CLOPIDOGREL 75MG PO/OD

3.INJ.OPTINEURON 1 AMP IN 100ML NS IV/OD

4.TAB ATORVAS 80MG PO/OD

5.PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS






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