CASE PRESENTATION:
By Dr Suleman Bashir
PGR(WMW)
PATIENT BIODATA
Name of patient: Zeeshan
Age/sex: 25/male
Occupation: supervisor at factory
Address: Okara
History was taken from patient brother
Date of admission: 29/11/2013
Mode of admission: emergency
PRESESENTING COMPLAINS
Difficulty in speaking - 1 day
Weakness of right side of body - 6 hrs
HISTORY OF PRESENTING ILLNESS
My patient known smoker and addict for charas and opium
for last 5 years and takes occassional alcohal was in USOH
1 day back when he complained of difficulty in talking and
numbness and weakness of his right side of body to his
friend while talking on phone then suddenly call was
disconnected
After sometime his roommates came and they found him
lying on ground and took him to the nearby hospital where
he was diagnosed as the case of poisoning and gastric
lavage was done and patient was admitted
HOPI(CONTD)
In hospital,patient was very irritable and moving all four limbs and shouting but words were not comprehensible.At night patient slept well.Next day at around 7 am he had 3 episodes of vomiting and the vomitus mainly contains the food product which was green in color and projectile.
His brother told that the patient was putting his hand on back of head and complaining of having pain
His brother also noticed weakness of right side of body while turning the patient in bed. Weakness remained static and didn’t progressed.
He got patient discharged and referred to mayo hospital where he was admitted.
There was no history of fever,rash, fits ,LOC or any drug intake or poisoning
SYSTEMIC REVIEW
No history of fever, cough, SOB, chest pain,
orthopnea, PND, palpitation
No history of fits, LOC, chronic headache,
photophobia or any such previous episodes
No history of any genitourinary complaint.
No history of any hakeem medication or drug intake
for any illness
PAST HISTORY
No history of Tuberculosis,Diabetes
Mellitus,Hypertension or any coagulopathy.
PERSONAL HISTORY
Education - middle
Occupation - work as a supervisior at factory
Drug abuser - takes opium, charas,alcohal
Smoker
SOCIOECONOMIC
Low socioeconomic status
FAMILY HISTORY
No history of diabetes, hypertension
tuberculosis,ischemic heart disease or any
coagulopathy
He has 6 siblings - 2 sisters and 4 brothers
DRUG HISTORY
No history of any drug allergy
DIFFERENTIAL DIAGNOSIS
Cerebrovascular accident
Space occupying lesion
Demyelinating disease (MS)
Poisoning
EXAMINATIONGeneral Physical Examination
A young male lying in bed propped up with brannula on left arm and spontaneous eye opening having following vitals:
Pulse : 64/min BP: 130/80mm of Hg
Temp : afebrile Respiratory rate : 16/min
Pallor :+ve Clubbing :-ve
Cyanosis :-ve Pedal edema: -ve
Jaundice: - ve kilonychia: - ve
JVP : not raised Lymph nodes :not palpable
Thyroid :not enlarged
No joint swelling
No rash
CNS EXAMINATION:
GCS: E4 V3 M6 = 13/15
SPEECH: wernick’s aphasia
Cranial nerves: right 7th nerve UMN palsy,rest nerves intact
MOTOR SYSTEM
Bulk in all four limbs- Normal
Fasciculation- Absent
Tone- decreased in rt upper and lower limbs
Power-0/5 in right upper and lower limbs and 5/5 in left
upper and lower limbs
Reflexes-
reflex Ankle knee brachio
radialis
biceps triceps
Right + + + + +
left ++ ++ ++ ++ ++
MOTOR CONTD
PlantersRight - upgoing
Left - withdrawal
Gait and coordination: couldn’t be assessed
CNS CONTINUE
Sensory system: limited sensory examination
done.in which patient respond to painful stimuli.
Cerebellar system : could not be assesed.
Extrapyramidal system : no abnormal added
movements noted.
Signs of meningeal irritation : absent
SYSTEMIC EXAMINATIONS CONTINUED.
Cardiovascular system
On inspection-No visible pulsations,No scar marks,No
chest deformity or prominent veins
Apex beat in 5th intercostal space medial to mid clavicular
line
On Auscultation-S1,S2 normal,no added sounds
Respiratory System - NAD
Gastrointestinal system - NAD
DIFFERENTIAL DIAGNOSIS
Cerebrovascular Accident
Space occupying lesion
Demyelinating disease
INVESTIGATIONS - ORDERED
CBC
RFTs, Serum electrolytes
LFTs
Urine C/E
PT/APTT, INR
Chest X-ray
ECG
Ultrasound abdomen and
pelvis
CT Brain
ANA,RA factor
Echocardiography
Serum lipid profile(fasting)
MRA- Scheduled on
13/12/13
INVESTIGATIONS - FOLLOWED
CBC:
Hb - 14.4,
Wbc - 8.6,
Platelets - 260,
MCV - 88
RFT
Creatinine - 0.8,
Serum Urea - 23
LFT
Bil - 0.6
ALT - 37
AST - 38
ALP - 219
Serum Electrolytes
Na -136,K-4.4
PT/APTT/INR - Normal
ANA/RA-Negative
Lipid profile:
TG-89,CHOL-136,HDL-35,LDL-69
ECG-normal
Chest x-ray - normal
Echocardiography - normal biventricular systolic function
FINAL DIAGNOSIS
Right uncrossed hemiplegia d/t
Intracerebral Haemorrhage
TREATMENT
Inj. Mannitol 150 cc iv 8 hrly
Inj. Dexa1cc iv 8hrly
Inj ctrox 1gm iv BD
Inj risek 40 mg iv OD
Syp duphalac 20cc po BD
Inj Ringer Lactate 1000 ml iv BD
CASE SUMMARY
A young 25 years old male smoker and drug abuser presented with complains of difficulty in speech and weakness of right side of body which was sudden in onset with no history of fever, rash, fits or LOC
On examination patient vitally stable with no significant finding on general physical examination.
On CNS examination there was wernickes aphasia and right 7th
cranial nerve palsy and right hemiplegia.
CT scan showed intracerebral hemorrhage on left parietal and basal ganglia area.
Final diagnosis of Intracerebral bleed was made.
CAUSES OF STROKE IN YOUNG PERSONS
Primary intracerebral haemorrhage Arteriovenous malformation
Drug misuse
Coagulopathy
Subarachnoid haemorrhage saccular aneurysm
AVM
Vertebral dissection
Cerebral infarct cardiac embolism Vasculitis
premature athesclerosis CADASIL
arterial dissection Neurovascular syphilis
Thrombophilia SLE
Homocysteinuria APLS