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