40 year old male came to OPD with C/O Giddiness, slurring of speech



40yr old male came to opd with complaints of Giddiness, slurring of speech , parasthesia and weakness of left upper and lower limb , difficulty in swallowing, Diplopia (Binocular) , hyperacusis left aural fullness since 1week 

HOPI 

Pt was apparently asymptomatic 1week back , then he had sudden onset of weakness of left lower and upper limb associated with slurring of speech and giddiness at around 2pm 1week back 

Pt had history of polio since childhood ,6 months of age 

He used to walk on B/L upper limb since childhood 

Weakness- sudden onset of left lower and upper limb , unable to roll on bed, unable to walk on upper limb associated with parasthesia of left half of the body 

Able to lift the hand above shoulder 

Giddiness ( self reeling ) - increasing with sitting , not associated with nausea, vomitings , headache 

No bowel and bladder incontinence

No loss of consciousness, seizures , palpitations, sweating , sob

In village health checkup he was diagnosed to have hypertension and was put on Telma 40mg 


PERSONAL HISTORY 

Diet - mixed 

Appetite - Normal 

Bowel and bladder- regular 

No allergies 

Alcohol- since 20yrs 2-3 times / week 

90ml/day 

 

FAMILY HISTORY - not significant 


GENERAL EXAMINATION 

Pt is c/c/c 

No pallor , icterus, cyanosis, clubbing, lymphadenopathy, koilonychia , oedema 


VITALS 

   Temp- Afebrile 

    PR- 88bpm

    RR - 12cpm 

    Bp- 140/8mmhg 

    Spo2 - 99%RA 

    Grbs- 128 mg% 


SYSTEMIC EXAMINATION 

 CVS- s1s2 + 

 RS- BAE+ , NVBS heard 

 P/A - soft , no tender 

 CNS 

  CNS- oriented to time,place,person

memory : recent, remote intact

speech: slurred,

 dysarthria.

 cranial nerves:


6 - Rt Pallor : present  rectus palsy 


8- left side air conduction more than bone conduction ( Rinne’s)

Weber’s- patient cannot confirm the lateralisation 

9-deviation of uvula to right side





Rest of the cranial nerves are normal 
*motor*:
*tone* :-b/l UL-normal
b/l LL-flaccid
*power* 4/5 in left upperlimb ,5/5 in right upper limb
2/5 in left lower limb, 2/5 in right lower limb 
reflexes :biceps:b/l: +
triceps +, supinator+, knee -, plantars: b/l mute


sensory: crude ,pain,temp, fine touch, joint position, proprioception are normal in all dermatomes

cerebellum- 
finger nose- normal
Finger finger test normal
No Nystagmus,

Gait:cannot be elicited

Provisional diagnosis:
Left CVA- Left hemiparesis secondary to acute infarct in ? Right pons with hypertension 

Rx:
1. RT feeds 100ml milk 2nd hrly ; 50ml water hrly
2.Inj pantop 40mg IV/od 
3. Tab ecospirin 150 mg        
Rt/0d  
4. Tab Atorvas 40mg Rt/od  
5. Physiotherapy of left upper and lower limbs 
6. Inj . Zofer 4mg lv/sos 






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