68 Male patient k/c/o of HTN with slurring of speech

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CHEIF COMPLAINTS

68 year old male patient resident of deverakonda Telangana  farmer by occupation , uneducated .

Right handed individual 

Informant - son 

  1. Giddiness since one month 
  2. Weakness of right upper limb 3 days ago
  3. Slurring of  speech since 3 days ago
Date of admission - 14/06/2023 
Date of examination -15/06/2023
HISTORY OF PRESENTING ILLNESS 

sequence of events 




Patient was apparently asymptomatic one month ago when experienced giddiness or the world spinning around him , taking the matter into consideration he took himself to a private hospital where he was diagnosed with hypertension and was prescribed medication , patient consumed the tablets only until symptomatic relief , later was non complaint .

Patient continued to have such episodes of giddiness and consumed the tablets prescribed whenever he felt giddiness and started using a stick for support while walking .

one week ago patient woke up around 7am and had his breakfast just then he fell unconscious and was rushed to the hospital where he was given glucose injection and patient recovered ,sent back home later he even built a wall for his cattles 

3 days ago patient was sitting outside his house with his neighbours and having a chat , just then his son had come from work and noticed that his fathers speech was a bit slurry.


An hour later ,patient son took him to the MRO office regarding some work on a bike and when the work had finished he dropped him back at the house ,son noticed his father slurring speech had progressed further ,He was able to comprehend speech and follow command but was unable to phrase words or sentences.

Then  the patient started unbuttoning his clothes while sitting at the entrance door, unable to use his right hand to unbutton his shirt, he used his left hand to do so .Son  assuming he wished to take a shower and left for his work 

later the patient’s son gets a call from his mother saying his father had fell weak and that  he developed acute onset weakness of right upper limb, with difficulty in lifting arm over head to reach objects, difficulty in holding a glass of water and 
and was unable to walk and unable to speak .

The son rushed back home called for a ambulance and patient was taken to government hospital in deverakonda 

They performed CT scan and informed patients about infract in his brain 

patient weakness in right upper limb recovered after treatment at the hospital but his speech remained slurry 

In this view , he was brought to our hospital.

no associated deviation of mouth , dribbling of saliva ,patient was able to close his eyes 
  • No history of trauma, fever
  • No history of headache, vomiting
  • No history of loss of consciousness or seizures
  • No history of decreased smell, blurring of vision, double vision, decreased sensation over face, decreased hearing or vertigo, difficulty in swallowing or nasal regurgitation on swallowing and no hoarseness of voice
  • No history of tremors
  • No history of chest pain or palpitation

PAST HISTORY 


patient is K/C/O of hypertension since one month .

history of  loss of consciousness in the past 

No similar complaints in past 

No history of chest pain , TB , epilepsy , cardiovascular disease

FAMILY HISTORY   

No similar complaints in the family 
No significant history 

SURGICAL HISTORY 
No history of surgeries in recent past 

MEDICAL HISTORY 

Patient was prescribed these medication on his visit to hospital due to loss of consciousness one week ago 








PERSONAL HISTORY

Daily routine 


Patient wakes up at around 7 am everyday 

Hops into the shower and sits for breakfast by 8am 

Has his meal and goes around house to house in his neighbourhood to have a chat with his friends 

Comes back home at 1pm to have lunch 

And later spends time in the house ,looks after his cows 

spends his time in leisure until 8pm 

Has his last meal of the day 

Goes to sleep by around 8:30-9pm 

patient is 68 year old male , married since 34 years with two children elder daughter and a younger son 

Patient was never received education ,started working as a farmer at the age of 18 years and stopped working one year ago due to shortness of breath and handed over his job to his son 

Who currently performs most of the field work .

diet - mixed ,currently on RL slow infusion 




Appetite- normal 

Sleep - adequate 

bowel and bladder - patient is able to walk to the washroom and empty is bladder on his own but is accompanied by his family member for support if he ever falls , complaints of incomplete emptying of bladder .

Addictions - consumes alcohol occasionally , last consumed 5 months ago 

Usual quantity consumed is 90 ml 

SUMMARY 

  • hypertensive elderly man with sudden onset, progressive Paralysis of right sided upper limb ,unable to comment on sensation over face due to  associated aphasia. 
  • History is suggestive of of acute neurological deficit probably due to ischemic stroke involving left MCA territory


General Physical Examination

  • A elderly man who is moderately build and nourished is conscious and cooperative and cannot comment orientation due to aphasia 
  • Patient is right handed
  • Pallor: Not seen
  • Icterus: Not seen
  • Cyanosis: Not seen
  • Clubbing: Not seen
  • Lymphadenopathy: Not seen
  • Pedal Edema: Not seen


Vitals
  • Pulse: 82 beats per min, regular, normal in volume and character
  • Respiratory rate: 18 cycles/ min, abdominothoracic type
  • BP: 160/94 mm of Hg in left brachial artery on day of admission 
  • On day of examination-130/70mm of Hg 
  • Temperature: 98.6 degree Farenheit


Higher Mental Functions

  • Right handed individual
  • Conscious and cooperative, unable to comment on orientation to time place and person due to aphasia 
  • Appearance and Behavior: appropriate. 
  • Patient is emotionally stable
  • Calculation: unable to comment 
  • Speech: Speech fluency markedly reduced. Incoherent speech, Agrammatic speech ,Repetition is absent
  • Comprehension present but delayed . 
  • Patient is uneducated hence cannot comment on reading and follow 
MMSC score 

unable to comment and give him a proper score  due to his aphasia 

When asked to draw a figure 


https://youtube.com/shorts/F_HOL2WDmq4?feature=share

MOTOR SYSTEM 


NUTRITION 

               R.             L
  U/L        Normal.    Normal
  L/L.     Normal.       Normal


TONE:
        U/L.               R.          L.
   
                      Normotonia    Normotonia
         L/L 
                      Hypertonic.  Hypertonic 
    
  

POWER.            RIGHT.           LEFT.
SHOULDER

 flexion  :               5/5    5/5 https://youtube.com/shorts/W1WHEit_N4k?feature=share

 Extension        5/5.  5/5

Abduction     5/5.  5/5

Adduction         5/5.    5/5

Internal rotation 5/5.   5/5

External rotation    5/5.   5/5

Elbow:


Flexion.     5/5.   5/5

Extension:5/5.   5/5

Wrist:

Flexion:5/5.   5/5

Extension:5/5.   5/5

Abduction : 5/5.   5/5

adduction:5/5.   5/5

HIP

Flexion:5/5.    5/5 

Extension.  5/5.   5/5

Abduction:5/5.   5/5

Adduction 5/5.    5/5

Internal rotation:5/5.    5/5

External rotation.  5/5.    5/5



Knee 

Flexion 5/5.    5/5

Extension.   5/5.   5/5 

Ankle.  5/5.     5/5

Plantarflexion:.   5 /5.    5/5


Dorsiflexion.     5/5.  5/5


Toe.   5/5 5/5


Movements:5/5


SENSORY SYSTEM 

Spinothalamic: Crude touch, pain, temperature normal on both sides on all limbs
Posterior column: Fine touch, Vibration, Position sense present on all limbs

Cortical: Two-point discrimination, Tactile localisation, Graphesthesia, Stereognosis cannot be assessed due to aphasia 

Language

1. Spontaneous speech


Present but impairment in articulation 

● Normal  Fluency - absent 
o Verbal fluency
Absent 
           

            2. Comprehension- Intact able to point out four objects 


Yes or no response - is this a hospital ? He said yes 

Is this ur wife ? Yes 

has ur speech impaired -yes 

Do u know any songs ? -yes 

Can u sing ? -yes 

u named someone just a while ago whose name was that ? Was it ur wife ?? -yes ( tired to say bharya)

Complex command - patient cannot articulate a proper sentence 


3.  Repetition  -absent  

 

4. Naming and Word finding- 


Due to aphasia cannot be assessed 

5.Reading - patient had never received education 

         6.Writing –



REFLEXES: 

Corneal present 

Conjunctival  present 

Abdominal: present 

Plantar: present 


DEEP REFLEXES:

Biceps :  1+.  1+
Triceps 1+.  1+
Knee : 5+. 5+
Ankle:  1+.  1+


Cerebellar Functions

  • Nystagmus: Not seen
  • Dysmetria/past pointing: Not seen
  • Intentional tremors: not seen
  • Dysdiadokinesia: not seen
  • Gait: normal 
  • No signs of meningeal irritation
  • Examination of skull and spine is normal
  • Ausculation of neck: no carotid bruit heard

PER ABDOMEN EXAMNATION

-Scaphoid

-No visible pulsations/engorged veins/sinuses

-Soft,non tender, no guarding and rigidity, no organomegaly

-Bowel sounds heard

SYSTEMIC EXAMINATION 

CVS

Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs


RESPIRATORY SYSTEM


Upper respiratory tract normal

  Lower respiratory tract :

-Trachea is central

-Movements are equal on both sides

-On percussion resonant on all areas

-Bilateral air entry equal

-Normal vesicular breath sounds heard

-No added sounds

-Vocal resonance equal on both sides in all areas


INVESTIGATIONS 



CT SCAN OF BRAIN PLAIN

FINDINGS:

Ischaemic changes noted in bilateral gangliocapsular region.

Small focal chronic lacunar infarcts noted in right side thalamus and left side basal ganglia.

Age related atrophy.

Rest of cerebral parenchyma shows normal gray / white matter differentiation.

Posterior fossa structures including fourth ventricle are normal.

Supratentorial ventricular system is normal.

Cortical sulci, sylvian fissures and basal cisterns are normal.

No midline shift.

No extra axial collection.

IMPRESSION:

• MILD CHRONIC CEREBRAL SMALL VESSELS ISCHAEMIC DISEASE CHANGES WITH SMALL FOCAL CHRONIC LACUNAR INFARCTS AS DESCRIBED ABOVE.



At 7:40 pm 
RBS -188 g/dl 
HB- 11g/dl
PCV-34 vol/%
TLC-8000cells /cumm
RBC -4 million /cumm
Platelet -2.75 lakh/cumm
Blood urea -32mg/dl
Serum creatinine -1.6mg/dl
Serum sodium-138mEq/dl
Serum K+- 3.6mEq/dl

SerumCL -1.3MEq/dl




Bilirubin 0.81

D. Bilirubin 0 . 20 


A/G Ratio 1.36


PROVISIONAL DIAGNOSIS 


Acute onset neurological deficit in the form of  right upper limb paresis with involvement of left hemisphere , probably involving MCA territory , with involvement of speech in the form of broca’s aphasia ,along with infarct in B/L gangliocapsular area with chronic infraction in Rt thalamus and left basal ganglia probable etiology of HTN and DM


https://www.ncbi.nlm.nih.gov/books/NBK563216/


CT scan seldom identifies lacunar ischemic insult within the first 24 hours due to its small size. If seen, lacunar strokes are ill-defined hypodensities on CT scans unless there is a hemorrhagic component to the acute stroke. A hyperdensity of a large artery on non-contrast head CT indicates the presence of a thrombus inside the arterial lumen or vessel calcification. Early infarct signs on non-contrast CT include loss of gray-white differentiation and focal hypoattenuation of brain parenchyma. These details are difficult to read in small subcortical strokes. Chronic lesions may appear as hypodense foci.

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