54F with quadriperisis and aphasia.

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A 54-year-old female brought to Casualty With complaints of 

involuntary movement of fist

Unable to speak and walk since two days.

she was apparently asymptomatic 13 years back then she developed generalised weakness with tingling and numbness of both foot and diagnosed with Diabetes, currently on Tab. Glimiperide  0.5mg and Tab. Metformin 500mg OD.

Three years back she had a episodes of involuntary movements of Fist (?focal seizures) associated with up rolling of eyes and subsided spontaneously

Two years back she had a history of left upper limb and lower limb weakness associated with transient loss of speech which resolved over 10 to 15 days and then she was started on Tab. Ecosprin 75mg, Tab. Clopitab 75mg, Tab. Rosuvastatin 20mg OD.

She had similar attacks of left upper limb and lower limb Weakness and transient loss of speech 11/2 year & 6 months back, Where is Speech resolved completely but residual motor weakness was present.

One month back history of giddiness  is associated with Fall where she went to nearest medical facility and diagnosed with hypertension and using Tab. Cilnidipin 10mg OD.

3 days back 

She had one episode of clenching of fist lasting for 30 mins while she was sitting on her chair, along with unrolling of eyes at 4am in the morning a/w involuntary micturation For which she was put on folyes catheter. Ever since, she hasn't been able to speak or walk.

History of high-grade fever Since 2 days Not associated with chills and rigors no burning micturation no vomitings & loose stools.

N/k/c/o TB,ASTHMA,CKD

O/E

Pt conscious, aphasic,confused,  it oriented to time place person.

Gcs= E4V1M1 6/15

Tone :

Rt upper & lower limb normal

Lt lower limb hypotonia.

Lt upper limb hypertonic.

Power - as patient was confused she didn’t obey commands thus couldn’t be elicited.

Reflexes

B/L biceps, triceps, supinator EXAGGERATED 

B/L ankle absent

B/L knee 2+

B/L plantar flexors

Once the patient was shifted to ICU her vitals were:

Bp - 140/100

PR - 99bpm

Afebrile

Grbs 300mg/dl

GCS - E4 V1 M1 

No response to painful stimuli

Pupils - left pupil reacting to light 

No neck stiffness

Her upper limb reflexes were all 3+

Knee reflex 2+

Ankle reflex was absent 

Plantars were Flexor 

Tone was hypersonic in left upper and lower limb 

On auscultation of the lungs - wheeze was present bilaterally on IMA

In view of poor GCS, she was intubated at 11 30pm yesterday. 

Her MRI brain shows acute infarcts in left ACA territory