55 year old male patient with recurrent CVA,HTN,since 3 years

 

General medicine

M.Devisree gupta

Roll no 81

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Chief complaints

Patient was brought to the casualty with complaints of inability to speak since 6 hrs, weakness in right upper and lower limb since 6 hrs and deviation of angle of mouth to left since 6hrs.

HOPI : Patient was apparently asymptomatic 6hrs back ,then he developed inability to speak since 6 hrs, weakness in right upper and lower limb since 6 hrs and deviation of angle of mouth to left since 6hrs.

No h/o fever, seizures

Past history:

History of CVA 2 years back.He got admitted in a local hospital and recovered.

History of hydrocele surgery 6months back

N/k/c/o DM

Personal history:

Mixed diet,normal appetite,sleep Adequate,bowel and bladder movement regular

Addictions - alcoholic and smoker for 30 years

General examination 

Patient is conscious 

PR- 104 bpm

RR-20 cpm 

BP-130/70 mm of Hg

Spo2 -92% on room air

Grbs- 126 mg/dl

Input/Output - 2800ml /1050ml

CNS Examination 

GCS- E4 V1 M5

Pupils - B/L NSRL

Reflexes

      Rt Lt

B - 3+. 3+

T - 3+. 3+

S- 2+. 2+

K - 3+. 3+

A - 2+ 2+

Plantar 

Right-Extensor Left-Flexor 

Tone- normal in all 4 limbs

Power - 2/5 in right upper and lower limb

4/5 in left upper and lower limb

RS-B/L air entry present ,grunting present 

CVS- S1S2present, no murmurs heard

PA- soft,non tender,bowel sounds +

Provisional diagnosis

Recurrent CVA with acute infarct in left frontal and temporal lobe with chronic lacunar infarcts in bilateral capsuloganglionic region with aspiration pneumonia with hypokalemia( secondary to ? Nutritional) with Hypertension since 3 years 

Treatment 

1.Ryles tube feeds- 200ml water hrly,200ml milk 4rth hrly

2.IV FLUIDS NS, RL @ 50 ml/hr 

3.TAB. ECOSPRIN 75mg RT/OD

4.TAB.CLOPIDOGREL 150mg RT/OD

5.TAB.ATORVASTATIN 40mg RT/OD 

6.Tab.AMLONG 5mg PO OD 

7.Physiotherapy

8.Monitor vitals

9.Position change 2nd hourly