case 30 - 60F with Acute stroke
28 July ,2021.
Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.
This is a case of 60 year old female (fruit and vegetable vendor) which chief complaints of giddiness, right upper limb and lower limb weakness and slurring of speech.
CHEIF COMPLAINTS:
Giddiness and generalised weakness around 6pm in the evening
Right upper limb & lower limb weakness and slurring of speech around 8pm in the night
HISTORY OF PRESENT ILLNESS:
Patient was apparently a symptomatic till 6pm in the evening. She suddenly started developing giddiness, after which the patient was taken to the local RMP and found BP was 160/80 mmHg
She was prescribed T.amlong 5mg and BP was lowered to (systolic 130mmHg)
Giddiness was non rotational, no postural variation, no change with position of the head, not associated with blurring of vision or headaches. Lasted for 30 min.
The taken to the local hospital where sublingual NTG was given.
followed by sudden onset of weakness of right upper & lower limbs and slurring of speech. Not able to lift/move the limbs from the bed.
No loss of touch, pain, temperature sensations on the right. Not associated with difficulty in swallowing, deviation of mouth, tip of tongue.
HISTORY OF PAST ILLNESS:
Not a k/c/o of diabetes mellitus, hypertension.
TREATMENT HISTORY:
Nothing significant
PERSONAL HISTORY:
Appetite : normal
Non vegetarian
Bowels: regular
Micturition: normal
FAMILY HISTORY:
Nothing significant
PHYSICAL EXAMINATION:
GENERAL :
Pallor - no
Oedema - No
No signs of icterus, cyanosis, clubbing of fingers/toes, lymphadenopathy
Mild dehydration
VITALS:
Temperature - afebrile
Pulse- regularly irregular
BP - 130/90 mmHg
SpO2: 96% at room air
GRBS- 160 mg%
SYSTEMIC EXAMINATION:
CVS:
S1, S2 heard
RESPIRATORY SYSTEM:
BAE +
PER-ABDOMEN:
Shape: scaphoid
Tenderness: absent
Bowel sounds: yes
No palpable mass, no organomegaly
CENTRAL NERVOUS SYSTEM
Level of consciousness : drowsy 1 arousable
Speech : slurred
Signs of meningeal irritation: none
Motor system: right - tone absent
Power - UL, LL
1/5 , 0/5
Sensory system : +
Glasgow scale: E4V5M6
INVESTIGATIONS:
1. Serum magnesium
2. HEMOGRAM
3. Liver function test
4. HBsAG:
5. Anti HCV antibodies:
6. ECG:
7. Lipid profile
8. RFT
9. HIV 1/2 rapid test:
FINAL DIAGNOSIS:
CVA - right hemiplegia
Acute infarct in para median aspect of both sides of the pons (left > right)
TREATMENT:
24/7/21:
Tab.Atorvas - 20 mg - HS
Tab.Ecospirin-75mg- OD
Tab.Clopidogrel -75mg-OD
25/7/21:
Tab.Ecospirin-75mg-OD
Tab.Clopidogrel-75mg-OD
Tab.Atorvas-20mg-HS
26/7/21:
Tab.Ecospirin-75mg-OD
Tab.Clopitab-75mg-OD
Tab.Atorvas-20mg-OD
27/7/21:
Tab.Ecospirin-75mg-OD
Tab.Clopitab-75mg-OD
Tab.Atorvas-20mg-OD
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