65 year old male with hemiparesis and loss of memory.

 65 yr old male farmer by occupation came with 

 chief complaints of 

Loss of memory since 1 yr 

Rt sided upper and lower limb weakness since 1 yr 

HOPI

The patient was apparently asymptomatic 1 yr ago then he developed sudden onset seizures for which he has admitted in the hospital . He was unconscious up to 12 hours. after gaining consciousness he had post icteal confusion had weakness in right upper and lower limb and observed that Right lower limb was involved more than his right upper limb due to which he was unable to walk. ( CRURAL HEMIPLEGIA )

He also developed deviation of mouth to the left side.

No h/o trauma, double vision.

 pt has also developed loss of memory for 1 year which was insidious in onset and gradually progressive the pt lost his recent memory and have partial remote memory

No h/o seizure activity again.

Past illness 

K/c/o cva 1 yr ago 

K/c/o HTN since 10 yrs ( on atenolol 50 mg and amlodipine 5 mg OD since 1 yr ) 

Not a k/c/o DM, cad, asthma, thyroid disorders, TB.

Personal h/o 

Appetite- normal

Diet - mixed

Bowel and bladder - regular

Any known Allergies- absent

Addictions-  consumption of alcohol ( 90 ml / day, 2 pack bidis / day since 40 years . )


Family h/o - not significant


On general examination - 

patient is conscious,coherent and cooperative 

Well oriented to time , place and person. 

There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy and bilateral pedal edema .  







Vitals- 

Temp - 99.2F

PR- 80 bpm

Bp- 150/70 mmHg

RR -20 cpm

Grbs - 118 mg/ dl 

Systemic examination -


CNS :  

Higher mental functions  

MMSE score - 16 



Conscious, oriented to person , place and time .

Speech : normal 

Memory: loss of recent memory 

No Visual hallucinations

No delusions 

No emotional lability. 

CRANIAL NERVE EXAMINATION:


1st   : Normal

2nd  :  visual acuity is normal               

3rd,4th,6th  :  normal                      

5th             :  sensory intact

                     motor intact

7th             :  normal

8th             :  No abnormality noted.

9th,10th     : palatal movements present and equal. 

11 th : intact 

12 th : normal 

Motar examination 

                                        R.              L

Tone                 UL           N                N

                          LL           N.              N 

 Power               UL 4/5.       4/5

                           LL   4/5.      4/5

Reflexes 

     B                             -.            -

     T.                            -              -

     S.                             -.            -

     K.                             -.             -

     A.                            -.             -

      P.                           Extensor flexor


Lobar function tests 








Frontal 

  1. He know about hospitalization
  2. did not give history  properly 
  3. No able memorize numbers orderly
  4. able to say phalam , Samayam , cinema 
  5. Able to 10 names of vegetables, animals in one minute  
  6. Motor luria test - done
  7. proverbs - able to say 
  8. Luria graphic test - able to draw triangle and square 

Orbital and  basal 


Go and no go test 


1.Direction - 2 errors 

2. color -able to say 


Parietal lobe


Ideational apraxia - able to perform folding of paper as shown . 

Right  left orientation- present 


Temporal lobe


Recent memory - absent 

Remote Memory - present but not able to recall some events 

Immediate memory present 

Delusion and hallucinations - absent 


Occipital lobe 

 

Prosopagnosia - present 

Visual memory 



SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

                              R                          L 

Crude touch : Normal                 Normal 


pain : Normal                              Normal 


temperature : Normal                 Normal 


DORSAL COLUMN SENSATION:

                                    R                         L 

Fine touch :         normal                    Normal 


Vibration sense : normal                    Normal 


Proprioception : normal                   Normal



CORTICAL SENSATION:

                                               R                   L 

Two point discrimination : normal           Normal 


Tactile localisation :  normal                   Normal 


CEREBELLAR EXAMINATION:


 Slight tremors are present  

Nystagmus -absent 


Finger nose test -


Per abdomen: 

Inspection -

Shape of abdomen : scaphoid

Umbilicus : inverted 

Movements of abdomen wall with respiration 

No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites 

On palpation -

No local rise of temperature 

Inspectors findings are confirmed 

Soft and non tender

No palpable mass 

Liver and spleen not palpable 

On percussion -

Resonance note heard

On auscultation -

Bowel sounds heard


R/S - inspection:

Trachea appears to be normal - Central 


shape of chest - elliptical 


Movements of chest appear to be bilaterally equal


No scars , sinuses present.

No drooping of shoulder

No engorged veins , swellings seen

No hallowing seen

No crowding of ribs


Palpation:

All inspectory findings are confirmed

No rise of temperature

No tenderness 

Trachea is in midline

B/L chest movements are equal

No swelling and palpable masses are felt

vocal fremitus are normal


PERCUSSION.                        RT.            LT

SUPRA CLAVICULAR       resonant.  resonant

INFRA CLAVICULAR.       resonant.  resonant

MAMMARY.                       resonant.  resonant

INFRA MAMMARY.           resonant.  resonant

AXILLARY.                         resonant   resonant

INFRA AXILLARY.             resonant   resonant

SUPRA SCAPULAR.        resonant   resonant

INFRA SCAPULAR.         resonant   resonant

INTER SCAPULAR.          resonant   resonant



Auscultation:


Normal Vesicular breath sounds heard


Cardiovascular system:

Inspection- 

No raised JVP

The chest wall is bilaterally symmetrical

No dilated veins, scars or sinuses are seen

Apical impulse at 5th intercostal space

Palpation-

Apex beat is felt in the fifth intercostal space, 1 cm medial to the midclavicular line

Percussion -

Right and left borders of the heart are percussed 

Auscultation-

S1 and S2 heard, no added thrills and murmurs are heard 


https://youtu.be/vepEWbdcTsQ


Provisional diagnosis -

Dementia under evaluation ?  right sided hemiperesis.

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