65yr/M with sudden painful diminision of vison along with generalized weakness in all the limbs since 2days of presentation.
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65yrs /M,farmer(not doing any work from6-7yrs).patient complaints of
1. sudden painful diminision of vision in both eyes (left>right)associated with headache
2. generalized weakness of both U/L &L/L
3.slurring of speech. since 2days
He was taken to the local hospital but there was no relieving of symptoms.pt was apparently asymptomatic 2days back then he suddenly developed all these symptoms.No complaints of diplopia, redness of eyes, ocular pain, trauma, lacrimation and itching.
No history of fever,pedal edema, palpitations,diarrheoea, vomitings,SOB.
Difficulty in walking is present but there is no difficulty in wearing slippers. No difficulty in holding objects but there is difficulty in switching objects from right to left and there is also difficulty in combing hair and buttoning of shirt. complaining of urinary incontinence since his admission.
k/c/o DM, HTN,and is on regular medication since 5 years.No h/o TB,asthma,burning micturition and constipation.
He was operated for hydrocele 1year back.
ON EXAMINATION:
patient is conscious,not oriented to place, time .Well built.
Afebrile
PR-84bpm
BP-150/100mmhg
CNS EXAMINATION:
Higher mental functions: orientation to time and palce: ( -) to person:(+)
Memory: Recent(-) Remote(+)
Cranial nerves: 1.Olfactory -intact
2.Visual acuity-only hand movements present at time of presentation but now counting fingers are present.
3,4,6 - intact ,extra ocular movements presents
5.Sensation of face and mastication present, jaw jerk also present
7- no drooping of eyelids and frowing. no deviation of angle of mouth.no loss of nasolabial fold.sensation of taste present.
8-Rinnes and webers - negative
9,10- gap reflex present and there is no deviation of uvula.
11-shrugging of shoulders present
12- no deviation of tongue
Motor system: RT LT
Bulk UL &LL N N
Tone. UL incresed N
LL N N
Power UL &LL 5/5 5/5
Reflexes:
biceps + +
ticeps + +
knee and ankle + +
superficial reflexes corneal, conjuctival, abdominal, and cremastric are present.
Sensory system: Posterior coloum- proprioception, fine touch, vibration, and joint position present
anterio spino thalamic tract - pain temp and crude touch are present.
Cerebellum: Rombergs and finger nose in cordination ,and dysdydokinesia are negative
Nsytagmus -negative.
CVS: s1 s2 heard, no murmurs
RS:BAE present, normal vesicular breath sounds were heard, no added sounds.Traches central in position
ABDOMEN-
Abdomen is obese,no tenderness and no palpable mass present.Hernial orifices are free.Liver and spleen are not palpable.Bowel sounds are present.
REFFERAL TO OPHTHALMOLOGY AND ORTHOPEDICS WERE DONE :
ORTHOPEDIC- in view of pain and swelling of b/l knee joints
OPHTHALMOLOGY-for visual acuity and fundus examination.
Both eyes
Disc- circular with well defined margins
Vessels -normal
Macula-not seen
INVESTIGATIONS:
ECG:
IRREGULARLY IRREGULAR PULSE AND ATRIAL PREMETURE COMPLEXES PRESENT IN ECG.
MRI BRAIN:
Acute ischemic infart in B/L occipital,parietal and frontal lobe with hemorrhagic transformation.
Acute infarts in MCA and PCA territories.
TREATMENT:
1.GRBS 8TH HRLY
2.INJ.HAI ACC TO SLIDING SCALE.
3.TAB.ATORVAS 20MG
4.MANNITOL 100ml /iv
5.BP-PR CHARTING.
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