70M with Left UMN Facial Palsy

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Parvathalu

Chief Complaints:
c/o of slurring of speech and deviation of mouth to the right side since yesterday morning.

HOPI: 
Patient was apparently asymptomatic 10 years back after which he had a history of a thorn prick to the left middle finger which formed a swelling filled with pus.

- Patient was diagnosed to have diabetes mellitus, after which his left middle finger was amputated. Since then, the patient is on regular diabetic medication.

-H/O of burning sensation and tingling in both lower limbs since 1 year

- Patient is having slurring of speech and deviation of mouth to the right side since yesterday morning

- No H/O weakness of limbs, seizures, trauma, headache/nausea, or fever.


Past history:
-K/C/O DM type 2 since the last 10 years (on regular medication, Glimi M1)

Personal History:
Diet: Mixed
Appetite: Normal
Bowel and Bladder Movements: Normal
Smoking: Regular smoker since 40 years - 40 pack years
Alcohol: Regular Drinker since 35 years. 


GENERAL EXAMINATION:
Pt is C/C1 /C
BP:130/80mm hg
PR:96bpm
RR:20/min
GRBS-261
Temp: Afebrile
CVS:S1S2+,No murmurs
RS :Bilateral air entry present
Normal vesicular breath sounds heard PA-soft, non tender, bowel sounds heard

CNS

Pupils-
left- Reacting to light
right- dilated, not reacting to light

Higher mental functions
Conscious
Oriented to time.place and person
Memory Intact
Speech - slurred

Cranial nerve examination
1- olfactory sense normal
2- visual acuity present
3,4,6-no ptosis Or nystagmus
5- corneal reflex present
7- deviation of mouth to right side, loss of nasolabial folds on left side
8- Normal hearing
*9,10- position of uvula is central Gag reflex-present
11- sternocleidomastoid contraction present
12- no deviation of tongue.

Motor system
Reflexes Right Left
Biceps - -
Triceps - -
Supinator - -
Knee. 1+. 1+
Ankle. - -
Plantars- Flexion Flexion

Power. Lt. Rt
Upper limb -4/5.4/5
Lower limb-4/5 4/5
TONE. Lt. Rt
Upper limbs N N
Lower limbs NN

No Involuntary movements

SENSORY SYSTEM
I-SPINOTHALAMIC R L
1. Crude touch N N
2. Pain. N. N
3. Temperature. N. N

II-POSTERIOR COLUMN
1. Fine touch. N. N
2. Vibration. N. N
3. Position sense. N. N
4. Romberg's sign -Equivocal

III-CORTICAL
1. Two point discrimination. N. N
2. Tactile localisation. N. N
3. Graphaesthesia. N. N
4. Stereognosis. N. N

CEREBELLAR Tests
No Nystagmus
Finger Nose test - normal
Heel Knee test normal
Dysdiadokokinesia - normal


Diagnosis
ACUTE ISCHEMIC STROKE (ACUTE INFRACT IN RT MIDDLE FRONTAL GYRUS/OPERCULUM INVOLVING RT ACA TERRORITY WITH LT UMN FACIAL PALSY)

Investigation
CT SCAN BRAIN: NO E/O ANY HEMORRHAGES IN BRAIN
HYPO DENSE AREA IS SEEN IN RIGHT FRONTAL AREA LIKELY INFRACT

USG ABDOMEN: CHOLELITHIASIS
LEFT MILD HYDRONEPHROSIS
GRADE 1 PROSTAMEGALY

2D ECHO: 
AORTIC VALVE CALCIFIED, THICKENED
RIGHT ATRIUM AND VENTRICLE NORMAL
LEFT ATRIUM: 3.4 CM
LEFT VENTRICLE: CONCENTRIC LVH,NO RWMA
EDD: 5.17 EF: 58%
CONCLUSION: MODERATE AR, TRIVAL AR NO MR, NO RWMA, MODERATE AS+, NO MS
DIASTOLIC DYSFUNCTION + NO PAH/PE

Treatment Given (Enter only Generic Name)
1. INJ OPTINEURON 1 AMP IN 500 ML/NS IV OD
2. INJ LEVIPIL 500 MG IN 100 ML NS IV BD
3. TAB ECOSPIRIN 75 MG RT/OD
4. TAB ATORVAS 40 MG RT/HS
5. SYP LACTULOSE 15 ML RT/HS

Advice at Discharge
1. TAB.LEVIPILL 500MG PO/BD X1WEEK
2. TAB.ECOSPIRIN 75MG PO/OD HSX1WEEK
3. TAB.ATORVAS 40MG PO/OD HSX1WEEK
4. TAB.METFORMIN 500MG PO/OD
5. PHYSIOTHERAPY OF FACIAL MUSCLES
6. ALCOHOL AND SMOKING ABSTINENCE 

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