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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