57 year old female with Monoplegia

 

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A 57 year old female came to casuality with complaints of weakness of the left lower limb with deviation of angle of mouth to the right side since 4 days.
[  ] History of presenting illness:
Patient was apparently asymptomatic four days back then she developed weakness of the left lower Limb which was insidious in onset, duration for about 1-2 hours and which relieved on medication. She was normal for 2 to 3 days then she again develop weakness of left lower limb with deviation of the mouth to the right side since today morning.
Slurring of speech present
There is no history of headache, vomitings fever and seizures.
No history of involuntary defecation or micturition.
[  ] Past history:
She had similar complaints in the past two years back ( left lower limb weakness- presence of chronic lacunar infarcts in right capsulogang region) for which she used aAntiplatelet medications for 2-3 months and then stopped.
She is a k/c/o Diabetes Mellitus type 2 since 4 years and takes OHA's.
K/c/o Hypertension since 5 years and uses
TAB.AMLONG 5MG
TAB. TELMA 40MG
TAB.HYDROCHLORTIAZIDE 12.5MG
[  ] Personal history:
She takes mixed, appetite is normal, sleep adequate, bowel and bladder habits are regular. She takes toddy and alcohol occassionally.

General Examination :
Patient is conscious, coherent, co- operative
No signs of pallor, icterus, cyanosis, clubbing, edema and lymphadenopathy.
[  ] Vitals at the time of admission:
Temp: Afebrile
PR: 113 bpm
BP: 180/90mm HG
RR: 22 cpm
SPO2: 98% at room air
GRBS: 180mg/dl
[  ] Systemic examination
[  ] Central Nervous System:
Cranial nerves- Intact
Sensory system- sensitive to touch and  pain
Motor system:
      Right                 Left
Power-  UL      4/5                    4/5
              LL      4/5                   4/5/3/5

Tone-    UL    Normal             Normal
              LL    Normal            Decreased

Reflexes-
Biceps            ++                       ++
Triceps           ++                       ++
Supinato        +                          +
Knee               -                            -
Ankl                -                            -
Plantar       Flexion              Extension
response

Gait- Hemiplegic

Cerebellar system - Intact

CVS: S1 S2 +
RS: NVBS +, BAE+
PER ABDOMEN: SOFT, NON TENDER, BOWEL SOUNDS+
[  ] PROVISIONAL DIAGNOSIS:
CEREBROVASCULAR ACCIDENT
WITH MONOPARESIS WITH LEFT UPPER MOTOR NEURON PLASY WITH ACUTE INFARCT IN THE RIGHT EXTERNAL CAPSULE, CORONA RADIATA, RIGHT CAUDATE NUCLEUS, RIGHT PUTAMEN

RIGHT RENAL SIMPLE CORTICAL CYST

[  ] TREATMENT
1.IVF NS AND RL @50ML/HR
2.T. METFORMIN 500MG PO/BD
3. T. ASPIRIN 150MG PO/OD
4. T. CLOPIDOGREL 75MG PO/OD/H/S
5.T. ATORVAS 40MG PO/OD/H/S
6.PHYSIOTHERAPY OF THE LEFT LOWER LIMB AND FACE.

DAY 1:
SOAP NOTES
S-
NO FRESH COMPLAINTS
O-

Temp: Afebrile
PR: 107 bpm
BP: 120/70mm HG
RR: 22 cpm
SPO2: 98% at room air
[  ] Systemic examination
[  ] Central Nervous System:
Cranial nerves- Intact
Sensory system- sensitive to touch and  pain
Motor system:
      Right                 Left
Power-  UL      4/5                    4/5
              LL      4/5                   4/5/3/5

Tone-    UL    Normal             Normal
              LL    Normal            Decreased

Reflexes-
Biceps            ++                       ++
Triceps           ++                       ++
Supinato        +                          +
Knee               -                            -
Ankl                -                            -
Plantar       Flexion               Flexion
response

Gait- Hemiplegic

Cerebellar system - Intact

CVS: S1 S2 +
RS: NVBS +, BAE+
PER ABDOMEN: SOFT, NON TENDER, BOWEL SOUNDS+

A-


CEREBROVASCULAR ACCIDENT
WITH MONOPARESIS WITH LEFT UPPER MOTOR NEURON PLASY WITH ACUTE INFARCT IN THE RIGHT EXTERNAL CAPSULE, CORONA RADIATA, RIGHT CAUDATE NUCLEUS, RIGHT PUTAMEN.

P-
1.IVF NS AND RL @50ML/HR
2.T. METFORMIN 500MG PO/BD
3. T. ASPIRIN 150MG PO/OD
4. T. CLOPIDOGREL 75MG PO/OD/H/S
5.T. ATORVAS 40MG PO/OD/H/
6.PHYSIOTHERAPY OF THE LEFT LOWER LIMB AND FACE.

DAY 2:

SOAP NOTES

S-
NO FRESH COMPLAINTS
O-

Temp: Afebrile
PR: 96 bpm
BP: 150/90mm HG
RR: 21 cpm
SPO2: 99% at room air
[  ] Systemic examination
[  ] Central Nervous System:
Cranial nerves- Intact
Sensory system- sensitive to touch and  pain
Motor system:
      Right                 Left
Power-  UL      4/5                    4/5
              LL      4/5                   4/5/3/5

Tone-    UL    Normal             Normal
              LL    Normal            Decreased

Reflexes-
Biceps            ++                       ++
Triceps           ++                       ++
Supinato        +                          +
Knee               -                            -
Ankl                -                            -
Plantar       Flexion               Flexion
response

Gait- Hemiplegic

Cerebellar system - Intact

CVS: S1 S2 +
RS: NVBS +, BAE+
PER ABDOMEN: SOFT, NON TENDER, BOWEL SOUNDS+

A-


CEREBROVASCULAR ACCIDENT
WITH MONOPARESIS WITH LEFT UPPER MOTOR NEURON PLASY WITH ACUTE INFARCT IN THE RIGHT LENTIFORM NUCLEUS EXTENDING INTO CORONA RADIATA

P-
1.IVF NS AND RL @50ML/HR
2.T. METFORMIN 500MG PO/BD
3. T. ASPIRIN 150MG PO/OD
4. T. CLOPIDOGREL 75MG PO/OD/H/S
5.T. ATORVAS 40MG PO/OD/H/S
6.PHYSIOTHERAPY OF THE LEFT LOWER LIMB AND FACE.