A case of hemiparalysis

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45 yr old male came to the casuality with the cheif complaint of weakness of right upper and lower limbs and slight deviation of mouth towards left in the morning

HISTORY OF PRESENT ILLNESS:

A 45 yr old male patient , construction worker by 

Occupation was apparently asymptomatic 2 days back and then developed 2 to 3 episodes of vomitings , food particles as contents and non blood stained .and then again asymptomatic till yesterday morning and then developed weakness of right upper and lower limb and mild deviation of mouth towards left .

patients also experienced headache , blurring of vision and giddiness.

---> patient normally wakes up at 6 am and

HISTORY OF PAST ILLNESS:

History of trauma 1month back and injury to upper right limb which resulted in pain and swelling and relieved on medication.

No history of diabetes ,hypertension ,asthma ,TB,epilepsy.

 PERSONAL HISTORY:

- Marital status : married 

-Diet:- mixed

-Appetite- normal appetite 

-Bowel and bladder movements - Regular

-Micturition : normal

-Sleep :- irregular

-Addictions:-patient has a habit of chewing gutka  and discontinued since 4 yrs

-Smoking - daily(2 packs a day)

-Alcohol : daily

-Drug addiction:- no

-Allergies :- no history of allergies.

FAMILY HISTORY :

no relevant family history

GENERAL EXAMINATION:

Patient was conscious non coherent and coperative moderately fit, moderately nourished and examined ina well lit room.

No Pallor, 

No Icterus,

No Cyanosis,

No Clubbing,

No oedema (pedal)

No Lymphadenopathy

VITALS :

Temp :- 98 ‘F

PR:- 89 bpm

BP: 120/90 mmHg

SpO2: 98% 

RR:- 20 cpm

SYSTEMIC EXAMINATION :

CVS : 

no thrills no murmurs

S1 and S2 are positive

RESPIRATORY SYSTEM :

vesicular breath sounds 

No dyspnea

No wheeze 

Central position of trachea

ABDOMEN :

Shape : scaphoid

No tenderness

No palpable mass 

No free fluid

Liver ,spleen -not palpable

Bowel sounds yes

CNS : 

Conscious

Speech : incoherent

Neck stiffness : no

PROVISIONAL DIAGNOSIS: 

Acute ischemic stroke involving left temporal, frontal and parietal lobe.