65 year old female

 A 65 year old female patient came to casualty with complaints of Involuntary movements of tongue, involuntary micturition and defecation since 2 days.

History of presenting illness:

Patient was asymptomatic 1 month ago. Then, she developed involuntary movement of tongue.

She had history of neck pain with back ache since 5 days. H/O vomitings since 2 days associated with nausea sensation, which was non bilious and non projectile.

Past History:

History of HTN AND DM present.

General physical examination:

Temp: afebrile

PR 90/min

RR 22 cpm

BP 130/70mmHg

SpO2 98%

Systemic examination:

CVS: S1 S2 +

RS: BAE+, NVBS +

CNS:

Patient is conscious, slurred speech 

 

Motor examination:                 

                      RIGHT                 LEFT

Tone :

UL                    incr                  incr

LL.                   incr.                 incr


Power:          

  

UL.                       4/5.              4/5

LL.                       4/5.               4/5


Reflexes:

Biceps                        +.       . +

Triceps.                     +.          +

Supinator.                +.          +    

Knee.                        +.          +

Ankle.                      +.          +

Plantar              Flexor.        Flexor 



Investigations:

Hemogram:

Hb 7.5 

TLC 11,000

PC 3.61

Na- 135, K - 3.7, Cl- 96


Random blood sugar



Serum electrolytes



Serum creatinine- 1.1



Blood urea - 33




Liver function test:


MRI


USG ABDOMEN:



Provisional diagnosis:

?CVA c ischemic stroke c Right side acute infarct in right frontal and parietal lobe ? Metastasis? Granuloma? Vasculitis?

Treatment:

Day 1:

Inj PAN 40mg IV/OD

Tab ASPIRIN 150mg/PO/OD

Tab CLOPIDOGREL 75mg/PO/OD/HS

Tab ATORVAS 40mg/PO/OD/HS

INJ HAI S/C , ACCORDING TO GRBS

INJ MANNITOL 100ml IV/BD

DAY2:

Inj PAN 40mg IV/OD

Tab ASPIRIN 150mg/PO/OD

Tab CLOPIDOGREL 75mg/PO/OD/HS

Tab ATORVAS 40mg/PO/OD/HS

INJ HAI S/C , ACCORDING TO GRBS

INJ MANNITOL 100ml IV/BD

DAY 3:

Tab PAN 40mg/PO/BD

INJ OPTINEURON 1amp in 100ml NS/IV/OD

Tab TETRABENAZINE 25mg PO/OD

INJ HAI ACCORDING TO GRBS

INJ ZOFER 4MG IV/SOS

INJ DEXA 8MG IV/BD

TAB LEVIPIL 500mg PO/BD

In view of ? Metastasis in brain, gynecology opinion taken in view of any pathology




DAY 4:

Tab PAN 40mg/PO/BD

INJ OPTINEURON 1amp in 100ml NS/IV/OD

Tab TETRABENAZINE 25mg PO/OD

INJ HAI ACCORDING TO GRBS

INJ ZOFER 4MG IV/SOS

INJ DEXA 8MG IV/BD

TAB LEVIPIL 500mg PO/BD

SYR CREMAFFIN PO/HS








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