55 MALE, WITH RECURRENT CVA


N ANJAIAH


Case History and Clinical Findings

C/O WEAKNESS OF LEFT UPPER AND LOWER LIMB , DEVIATION OF MOUTH TO RIGHT SIDE

SINCE MORNING

SLURRING OF SPEECH PRESENT SINCE MORNING

HOPI:

PATIENT WAS APPARENTLY ALRIGHT TILL TODATY MORNING ,THEN HE DEVOLOPED

WEAKNESS OF LEFT UPPER AND LOWER LIMB,INSIDIOUS IN ONSET ,GRADUALLY

PROGRESSIVE ASSOCIATED WITH DEVIATION OF MOUTH TO RIGHT SIDE,SLURRING OF

SPEECH PRESENT SINCE MORNING

NO H/O TRAUMA HEAD ,NAUSEA ,VOMITING , SCIZURES ,GIDDINESS

NO H/O FEVER,COLD ,COUGH

NO H/O CHEST PAIN,PALPITATIONS ,PND,ORTHOPNEA,BREATHLESSNESS

NO H/O ABDOMINAL PAIN,BURNING MICTURITION ,

PAST H/O :

K/C/O HTN ON T METXL 75MG PO.OD SINCE 3 YRS

K/C/O CVA LEFT HEMIPARESIS 10 YRS BACK

GENERAL EXAMINATION :

PT IS CONCIOUS , COHERENT AND COOPERATIVE , MODERATLY BUILT AND NOURISHED .

NO PALLOR, ICTERUS , CYANOSIS, CLUBBING ,LYMPHADENOPATHY, EDEMA

TEMP - AFEBRILE

PR- 60 BPM

RR-19 CPM

BP- 130/80 MMHG

GRBS -123MG /DL

SYSTEMIC EXAMINATION :

CVS - S1,S2 HEARD , NO MURMURS

RS - VESICULAR BREATH SOUNDS HEARD , NO WHEEZE AND DYSPNEA,NO CREPTS

P/A- SOFT , NON-TENDER , NO ORGANOMEGALY

CNS -

LEVEL OF CONCIOUSNESS: CONCIOUS

SPEECH: INCOHERENT

SIGNS OF MENINGEAL IRRITATION: NEGATIVE

CRANIAL NERVES: NAD

MOTOR SYSTEM:

R L

TONE:UL- INCREASED DECRASED

LL-INCREASED DECRASEDPOWER: 5/5( UL,LL) 0/5(UL,LL)

REFLEXES:

L R

BICEPS 2+ 2+

TRICEPS 1+ 1+

SUPINATOR - +

KNEE - 2+

ANKLE - +

PLANTARS- FLEXOR

COURSE IN HOSPITAL:

PATIENT WAS ADMITTED I/V/O

C/O WEAKNESS OF LEFT UPPER AND LOWER LIMB , DEVIATION OF MOUTH TO RIGHT SIDE

SINCE MORNING SLURRING OF SPEECH PRESENT SINCE MORNING

AND WAS INVESTIGATED FURTHER AND ON EVALUTION WAS DIAGNOSED AS

ACUTE ISCHEMIC STROKE SECONDARY TO INFRACT IN RT MIDDLE CEREBRAL ARTERY

TERITORTY

K/C/O HYPERTENSION WAS MANAGED CONSERVATIVELY

Investigation

COMPLETE URINE EXAMINATION (CUE) 22-03-2024 07:31:PMCOLOUR Pale

yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +SUGAR NilBILE

SALTS NilBILE PIGMENTS NilPUS CELLS 3-6EPITHELIAL CELLS 2-3RED BLOOD CELLS

NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

HBsAg-RAPID 22-03-2024 07:31:PM NegativeAnti HCV Antibodies - RAPID 22-03-2024 07:31:PM

Non Reactive

BLOOD UREA 22-03-2024 07:31:PM 30 mg/dl 42-12 mg/dlSERUM CREATININE 22-03-2024

07:31:PM 1.5 mg/dl 1.3-0.9 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 22-03-2024 07:31:PMSODIUM 146 mmol/L 145-136

mmol/LPOTASSIUM 4.5 mmol/L 5.1-3.5 mmol/LCHLORIDE 108 mmol/L 98-107 mmol/

L

LIVER FUNCTION TEST (LFT) 22-03-2024 07:31:PMTotal Bilurubin 2.00 mg/dl 1-0 mg/dlDirect Bilurubin

0.42 mg/dl 0.2-0.0 mg/dlSGOT(AST) 24 IU/L 35-0 IU/LSGPT(ALT) 26 IU/L 45-0 IU/L

ALKALINE

PHOSPHATASE 162 IU/L 128-53 IU/L

TOTAL PROTEINS 7.5 gm/dl 8.3-6.4 gm/dl

ALBUMIN 4.28 gm/dl 5.2-3.5 gm/dl

A/G RATIO 1.33



HEMOGRAM ( 22/3/24)

HB: 17.OMG/DL

TLC; 13,000 CELLS/CUMM

N/L/E/M/B: 55//44/01/0

PCV: 27.8VOL%

MCV: 65.1FL

MCH: 22.9 PG

MCHC: 35.2%

RBC COUNT: 4.27 MILLIONS/CUMM

PLATELET COUNT: 2,5 LAKH/CUMM

SMEAR:NORMOCYTIC NORMOCHROMIC ANEMIA WITHLEUKOCYTOSIS


Treatment Given:

IV FLUIDS 1PINT NS WITH 1 AMP OPTINEURON IN 500ML NS/IV OD

TAB ECOSPIRIN GOLD PER ORAL /HS

TAB PCM 650MG PER ORAL /SOS

HEAD END ELEVATION UPTO 30 DEGREES

PHYSIOTHERAPHY OF LEFT UPPER AND LOWER LIMBS


Advice at Discharge

TAB ECOSPIRIN GOLD PER ORAL /HS X TO BE CONTINUED

PHYSIOTHERAPHY OF LEFT UPPER AND LOWER LIMBS



LEARNING POINTS-

55 MALE, WITH RECURRENT CVA (NOT UNDER MEDICATION)

RISK FACTORS - HYPERTENSION (UNCONTROLLED)

OCCASIONAL ALCOHOLIC 

WITH MCA RIGHT INTERNAL CAPSULE INFARCT 


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