34yr old man , as a working driver presented in swallowing since 5am Weakness in Right UL and LL since 5am
Deviation of mouth to left since 5 am
Slurred speech since 6am .
Pt developed sudden onset of difficulty in swallowing while he tried drinking water followed by he suddenly developed weakness of rt upper limb and rt lower limb .
His attendant later observed deviation of mouth towards left side and slurring of speech.
H/o ? 1episode of GTCS 3years back, the patients attendant says they were also told that he had a heart problem back then.
He has been an occasionally alcoholic since 20years .
Not a known case of Htn ,Dm type2, Thyroid disorder,
Asthma.
No history of any past surgeries.
On examination
A well nourished and obese individual with no pallor, Icterus, clubbing, cyanosis or lymphadenopathy
Though he had bilateral pitting type of pedal edema extending upto his knees
His Abdominal girth measured around 96cms
He had no neurocutaneous markers
Spine is normal
A patch measuring around 4 x 3cms was present near his sacral region
He has a tattoo measuring 6x5cm on the upper aspect of his left mid arm
And another Tattoo measuring 10x 8cms on right arm
We also noticed multiple patches on his inner aspect of thighs and legs - upon asking, he said he gets them after eating chicken or egg.. He consumed eat fried rice 2 days prior to admission.
The patient was conscious and cooperative and he was well oriented to time, place and person
Speech - his palatals and labial were affected
On Lobar Function Examination
Frontal lobe:
His memory was intact. He had insight to his problems.
His social behaviour was good and his micturation was normal.
Parietal lobe:
Motor sequencing was intact - we asked him to button and unbutton his shirt and take off his shirt.
His right to left orientation, finger recognization, visuo spatial orientation were intact.
He was able to perform calculations, both simple and complex ones. We asked him to calculate - 14 + 4 x 3 x 3 ÷ 3
We asked him to write down his name - Dysmetria, there was overshoot while writing
Temporal:
His memory was intact
Occipital:
He was able to recognize familiar face and his visual memory was intact
Cranial Nerve Examination:
2 - Right homonymous hemianopia +
5th nerve -
Corneal reflex absent in the right eye and while checking the right eye the patient didn't blink the left eye
Conjunctival reflex absent in the right eye
3rd nerve - partial ptosis of right eye
6th nerve - restricted abduction
7th nerve -Reduced wrinkling on the right side of the face
Unable to raise eyebrows on the right side
Nasolabial fold on the right side - is less prominent
Deviation of mouth to the left
On clenching teech, mouth is deviated to the left
8th nerve - vestibular part:
The Hints test:
Head impulse - Bidirectional nystagmus + with the fast component to the right
Horizontal nystagmus +
Vertical skew test +
Rotational nystagmus +
9th nerve - No tenting of the soft palate
10th nerve - Gag reflex is absent
12th nerve - Tongue power reduced on the right side
Sensory examination:
Spinothalamic- Pain, temperature reduced on the right side
( contralateral to the side of the lesion)
Posterior column- fine touch, vibration, joint position - intact
Cortical- sterognosis, graphthesias, two point duscrimination, tactile localisation intact
Cerebellum:
Broad based ataxic gait +
Nystamus+
Unable to perform finger nose test
Individual muscle examinations for power were performed
All the upper limb muscles were 5/5 bilaterally
Lower limb muscles
Right hamstring and quadriceps were 4/5
Other muscles were 5/5
Examination was done along with Dr Aditya, Dr K Vaishnavi, Dr Usha, Dr Raveen and Dr Geeta
Investigations:
ECG: 21-01-2020
Chest X-Ray: done on 21-01-2021
Haemogram : 21-01-2021
LFT : 21-01-2021
RFT:21-01-2021
PT : 15 sec; APTT : 31 sec; INR : 1.11; BT : 2min 30sec; CT : 4min
Serology ; negative
2D - ECHO : 21-01-2021
CT- Scan: 21-01-2021
USG Abdomen and pelvis : 21-01-2021
Treatment on 21-01-2021:
1. Ryles tube insertion
2. Inj. PANTOP 40mg IV/OD
3. Inj. Zofer 4mg IV/TID
4. Monitor vitals
6. IVF 2 units NS @ 75ml/hr
7. GRBS charting 6th hourly
8. Add Tab. ECOSPRIN 150mg PO/HS
9. Tab. Tab. ATORVAS 40mg PO/HS
MRI : 22-01-2021
Treatment : 22-01-2021
1. Head end elevation
2. RT feeds - 100ml milk with 2 scoops of protein powder 4th hourly, 100ml free water 2nd hourly.
3. Inj. PANTOP 40mg IV/OD
4. Tab. BACLOFEN 10mg PO/BD
5. Tab. ECOSPRIN 150 mg PO/HS
6. Tab. CLOPITAB 75mg PO/HS
7. Tab. ATORVAS 40mg PO/HS
8. Monitor vitals - PR, BP
9. GRBS charting 6th hourly
10. IVF 2 units NS @ 75ml/hour
11. Inj. ENOXAPARIN 60mg SC/12th hourly
12. Inj. MANITOL 100ml IV/ TID
ECG: 23-01-2021
Haemogram :
Carotid Doppler :
Treatment : 23-01-2021
1. NBM until further orders
2. Inj. MANITOL 100ml IV/ TID
3. Inj. PANTOP 40mg IV/OD
4. Tab. BACLOFEN 10mg PO/BD
5. Tab. ECOSPRIN 150 mg PO/HS
6. Tab. CLOPITAB 75mg PO/HS
7. Tab. ATORVAS 40mg PO/HS
8.Inj. ZOFER 4mg IV/TID
9.IVF 2 units NS @ 75ml/hour
10. GRBS charting 8th hourly
11. Monitor vitals - PR, BP
Date: 24-01-2021
Haemogram
ECG :
Treatment :
1. Head end elevation
RT feeds - 100ml milk with 2 scoops of protein powder 4th hourly, 100ml free water 2nd hourly.
2. Inj. MANITOL 100ml IV/ TID
3. Inj. PANTOP 40mg IV/OD
4. Tab. BACLOFEN 10mg PO/SOS
5. Tab. ECOSPRIN 150 mg PO/HS
6. Tab. CLOPITAB 75mg PO/HS
7. Tab. ATORVAS 40mg PO/HS
8.Inj. ZOFER 4mg IV/TID
9.IVF 2 units NS @ 75ml/hour
10. GRBS charting 8th hourly
11. BP/PR/RR/SpO2 charting
12.Syp. LACTULOSE 10ml in a glass of water BD
13.Tab. RAMIPRIL 2.5mg PO/OD
14.Tab. METXL 12.5mg PO/OD
Date: 25-01-2021
ECG:
Treatment:
1. Head end elevation
RT feeds - 100ml milk with 2 scoops of protein powder 4th hourly, 100ml free water 2nd hourly.
2. Inj. MANITOL 100ml IV/ TID
3. Inj. PANTOP 40mg IV/OD before breakfast
4. Tab. BACLOFEN 10mg PO/SOS
5. Tab. ECOSPRIN 150 mg PO/HS
6. Tab. CLOPITAB 75mg PO/HS
7. Tab. ATORVAS 40mg PO/HS
8.Inj. ZOFER 4mg IV/TID
9.IVF 1 units NS @ 75ml/hour
10. Tab. RAMIPRIL 2.5mg PO/OD
11. Tab. METXL 12.5mg PO/OD/HS
12.Syp. LACTULOSE 10ml in a glass of water BD
13.Inj. Clexane 0.4ml S/C OD
14.Physiotherapy : passive movements, stretching exercises, assisted exercises.
15. BP/PR/RR/SpO2 charting
16. GRBS charting 12th hourly
Date :26-01-2021
Treatment :
1. Head end elevation
RT feeds - 100ml milk with 2 scoops of protein powder 4th hourly, 100ml free water 2nd hourly.
Inj.AMIODARONE 150mg given over first 10min f/b Inj.AMIODARONE 300mg over the next 6hours (10ml/hr) f/b Inj.AMIODARONE 540mg over the next remaining 18hours (5ml/hr)
2. Inj. MANITOL 100ml IV/ TID
3. Inj. PANTOP 40mg IV/OD before breakfast
4. Tab. BACLOFEN 10mg PO/SOS
5. Tab. ECOSPRIN 150 mg via RT/HS
6. Tab. CLOPITAB 75mg OF vi’s RT
7. Tab. ATORVAS 40mg OD via RT/HS
8.Inj. ZOFER 4mg IV/TID
9. Inj. NEOMOL 100ml IV / SOS (if temp >101 degree Fahrenheit)
10. Tab. RAMIPRIL 5mg PO/OD through RT only if SBP is >/=110mmhg
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