A 85 yr old female with weakness of right upper limb and lower limb
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Name :- P. Sai Krupa Sri
Roll no :- 175
A 85 yr old female with weakness of right upper limb and lower limb
Chief complaints :
•Right sided weakness of hand and leg since 1 day
History of present illness :
•Patient was apparently asymptomatic 1 day back
•later she developed weakness of right sided upper and lower limb which is sudden in onset associated with deviation of mouth to the left , head fixed to left side.
•No History of seizures and no History of loss of consciousness and no history of headache and vomiting.
Past history :
• no similar complaints in the past
•Patient is Known case of hypertension since 10 yrs she was on medication tab telma 40mg
•The patient went to near by hospital with complaint of burning sensation 4yrs back she was on sedative
•No History of diabetes , tuberculosis , asthma , epilepsy , thyroidal illness and HIV
Personal history :-
Diet - mixed
Appetite - normal
Sleep - adequate
Bowel and bladder movement - regular
No addictions
Family history :-
Not significant
General examination:-
Patient was conscious , not cooperative ,not oriented to time, place ,person.
Moderately built and moderately nourished
No pallor
No icterus
No cyanosis
No clubbing
No pedal edema
No lymphadenopathy
VITALS:
Temperature : Afebrile
pulse rate : 89 bpm
Respiratory rate : 22cycles / min
BP: 150/90mmHg
SpO2 - 98% at room air
Systemic examination :-
CNS :-
Higher mental functions:
• Consciousness is present
• Speech - global aphasia
Motor system :
Tone Right Left
Upper limb increase normal
Lower limb normal normal
Power :
Upper limb - 0/5 5/5
Lower limb 1/5 5/5
Reflexes Right Left
Biceps. 3+ 2+
Triceps. 3+ 2+
Supinator. 3+ 2+
Knee 3+ 2+
Ankle 1+ 1+
Plantar. Extension Flexion.
Abdominal reflex - absent
CVS - S1, S2 heard , No murmurs
RS - BAE +, NVBS +
P/A - Soft, Non tender
Investigation:-
Hemogram :-
•Hemoglobin: 13.1
•TLC: 13,200
•neutrophils : 85
•lymphocytes: 9
•eosinophils: 2
•monocytes : 4
•PCV : 39.6
•MCV: 75.9
•MCH: 25.2
•RBC : 5.35 million cells/ micro liter
•Platelets : 3.35 lakhs
LFT:
•total bilirubin : 1.21
•DB: 0.31
•AST: 16
•ALT: 16
•AKP: 222
•total proteins : 7.4
•Albumin : 4.23
•A/G: 1.33
RFT
•Blood urea : 34
•creatinine : 0.7
•sodium: 144
•Potassium : 3.6
•chlorine: 97
Ultra sound :-
Colour Doppler 2D ECHO :-
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