SHRUTHI ARUKONDA 02

 GENERAL MEDICINE. 


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.


                     CASE SHEET 

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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