75-year-old male presented with chief complaints of Left-sided weakness and deviation of the mouth to the right side.

CHIEF COMPLAINT -a 75-year-old male presented with chief complaints of Left-sided weakness and deviation of the mouth to the right side. 


HISTORY OF PRESENTING ILLNESS - 

The patient was apparently asymptomatic till 5pm yesterday 

At 5 pm -He could not hold the teacup with his hands and spilled it all over him. Following which his wife applied lotion over his abdomen and they had dinner and watched TV.

At 2 am - He called his wife because he could not move his left UL and he couldn't talk properly and there was a deviation mouth to the right. He could not contain his urine - his wife recollects. (he arrived at the hospital with foley's catheter)

 At 5 am - He went to a local hospital which diagnosed him with Left Upper limb Monoplegia with Right-sided UMN palsy

CT scan was done

At 9 am - The patient arrived at our hospital. His complaints were the above but we also noticed that he had Left Lower limb weakness. He Could swallow water when given in bottle caps

At 8 pm - The above complaints were persistent and he had a decreased ability to swallow - RT was inserted

PAST HISTORY - 

Known case of 

  • Hypertension from the past 8 years
  • Diabetes Mellitus from the past 8 years 
No history of -
  • fall or trauma, fever, epilepsy
  • similar complaints in the past  

DRUG HISTORY- 

  • The patient stopped  his Hypertension Medication 15 days ago (no clear reason given ) 

PERSONAL HISTORY 
  • The patient occasionally consumed toddy
  • He does not smoke/consume tobacco or beedi.
  • Diet - Mixed
  • Appetite - Normal
  • Sleep - Normal
  • Bowel and bladder - has not passed stools since yesterday


FAMILY HISTORY 

  • No relevant family history 

GENERAL EXAMINATION 

  • The patient was conscious, coherent, and cooperative. He was oriented to time, place, and person. 
  • Moderately built and nourished.
  • No pallor, Icterus, Cyanosis, Lymphadenopathy.




VITALS 
  • Temperature-Afebrile
  • BP -160/100mmof Hg
  • PR- 80 beats per minute 
  • RR -16 cycles per minute
  • SpO2 -96%
  • GRBS -126

RESPIRATORY SYSTEM 
  • BAE Present 
  • NVBS Heard
  • Trachea -Central

CVS EXAMINATION - 
  •  S1 S2 Heard
  •  No murmurs

PER ABDOMEN 
  • Soft and non-tender
  • Bowel sounds heard.

CNS EXAMINATION
  • Cranial nerves - Normal, except
    • Deviation of mouth to Right side and inability to shrug the left shoulder 
    • Recently decreased ability to swallow
  • Sensory System - Normal
  • Motor System -
    • Power - Decreased in LT UL and LL
    • Tone - Decreased in LT UL and LL
    • Reflexes
    • RT. LT.
    • B 2+ 2+
    • T 2+ 2+
    • S 2+ 2 +
    • K 3+ 3+
    • A 1 + 1+
    • Plantar: flexor , extensor 

PROVISIONAL DIAGNOSIS- 

CVA ; Left Hemiparesis 2⁰ to? Acute infarct in Right Internal Capsule Right MCA territory

PLAN OF MANAGEMENT 

Admitted in AMC and following investigations were sent -
CBP, RFT, FLP, RBS, HbA1c, CXR PA view

INVESTIGATIONS 

1.Hemogram, FBS, Blood Urea, Lipid Profile, Serum creatinine, Serum electrolytes 



2.Chest X-ray 


3. MRI BRAIN PLAIN - 19/7/2021









4. TPR GRAPH SHEET - 




5. 2D ECHO Report Screening (bedside) 20/7/2021


6. BP, PR, SPO2 monitoring 
















TREATMENT - 19/7/21
  1. Tab. ECOSPIRIN 150 MG OD / RT
  2. Tab. CLOPITAB 75 MG OD/ RT
  3. Inj. Optineuron 1 amp in 100 ml NS OD / i.v.
  4. Tab. PAN 40 MG OD/ RT
  5. Tab. ATORVAS 40 MG OD/ RT
  6. RT FEEDS - 100 ML WATER HOURLY AND 200 ML MILK 4TH HOURLY W/O SUGAR
  7. Inj. HAI s/c TID after GRBS
  8. BP/PR/SpO2/ Temp Monotoring
  9. INJ. Mannitol 100mg IV/TID
TREATMENT 20/7/21
  1. RT feeds- 150ml water 1hourly, 150 ml milk 4th hourly with 2-3 scoops of protein powder 4th hourly 
  2. Tab. ECOSPIRIN 150 MG OD / RT
  3. Tab. CLOPITAB 75 MG OD/ RT
  4. Tab. ATORVAS 40 MG OD/ RT
  5. Inj. Optineuron 1 amp in 100 ml NS OD / i.v.
  6. Inj. HAI s/c TID after GRBS
  7. BP monitoring  2nd hourly 
  8. Inj. Mannitol 100mg IV/TID
  9. NICARDIA 10 mg RT T
TREATMENT 21/7/21
  1. RT feeds- 150ml water 1hourly, 150 ml milk 4th hourly with 2-3 scoops of protein powder 4th hourly
  2. Tab. ECOSPIRIN 150 MG OD / RT
  3. Tab. CLOPITAB 75 MG OD/ RT
  4. Tab. ATORVAS 40 MG OD/ RT
  5. Inj. Optineuron 1 amp in 100 ml NS OD / i.v.
  6. Inj. HAI s/c TID after GRBS
  7. BP monitoring
  8. Inj. Mannitol 100mg IV/TID 
  9. Tab. Nicardia - 10 mg RT/TID 
  10. Tan. Riboflavin RT /OD
TREATMENT 22/7/21 8.30 am
  1. RT feeds- 150ml water 1hourly, 150 ml milk 4th hourly with 2-3 scoops of protein powder 4th hourly
  2. Tab. ECOSPIRIN 150 MG OD / RT
  3. Tab. CLOPIDOGREL 75 MG OD/ RT
  4. Tab. ATORVAS 40 MG OD/ RT
  5. Inj. Optineuron 1 amp in 100 ml NS OD / i.v.
  6. Inj. HAI s/c TID after GRBS
  7. TAB. TELMA /AMXPOX OD 40 mg /10 mg 
  8. TAB. RIBOFLAVIN 
  9. Position change 2nd Hourly 
  10. Physiotherapy of UL and LL 
  11. BP charting 
TREATMENT 22/7/21 8 PM 
  1. RT FEEDS 150 ML WATER 1 HOURLY (200 MLMILK PLUS PROTEIN POWDER 4TH HOURLY 
  2. Inj Monocef 1g IV BD 
  3. Inj Pan 40 mg iv OD 
  4. Inj HAI s/c TID
  5. Inj . NPH s/c BD
  6. Tab. Telma plus AMLONG  40 /10 mg 
  7. Tab. Ecospirin 150 mg RT/ OD 
  8. Tab . CLOPDOGREL 150 mg RT/OD 
  9. Tab. Atorvas 
  10. Inj Optineuron  1AMP 
  11. Tab Riboflavin 10 mg RT/OD
  12. Tab A to Z RT / OD 
  13. Physiotherapy of LL/RL
  14. BP/PR/Temp  charting 2 nd hourly 
  15. GRBS monitoring 4 th ourly 
  16. Air bed position change every 1 hourly 
TREATMENT 23 / 7/21

  1. RT FEEDS 150 ML WATER 1 HOURLY (200 ML MILK PLUS PROTEIN POWDER 4TH HOURLY
  2. Inj Monocef 1g IV BD
  3. Inj Pan 40 mg iv OD
    1.                 8 am, 1 pm,8 pm 
      • regular 6 U, 6 U, 6U 
      • NPH 10 U, x, 10 U 
    TREATMENT 24 / 7/21
    1. RT FEEDS 150 ML WATER 1 HOURLY (200 ML MILK PLUS PROTEIN POWDER 4TH HOURLY 
    2. Inj Monocef 1g IV BD 
    3. Inj. CLINDAMYCIN 
    4. INJ PAN 40 mg IV/OD
    5. INJ. INSULIN -  HAI    6U 6U 6U 
          • NPH  10U X  100
    6. TAB. TELMA 40 /10 RT OD
    7. TAB ECOSPIRIN  150 mg RT /OD 
    8. TAB CLOPIDOGREL 150 mg RT/OD 
    9. TAB ATORVAS  40 mg /RT / OD
    10. INJ OPTINEURON 1 amp 
    11. IVF- NS@ 100 ml per hour 
      • RL 
    12. PHYSIOTHERAPY of left UL and LL 
    13. INJ MANNITOL 100 ml / IV/TID 
    14. Air BED, position change every hour 
    15. GRBS monitoring 6th hourly 
    16. BP PR TEMP monitoring 
    17. THROMBOPHOE ointment for L/A on L arm 
    TREATMENT 25/7/21
    1. RT FEEDS 150 ML WATER 1 HOURLY (200 ML MILK PLUS PROTEIN POWDER 4TH HOURLY 
    2. Inj Monocef 1g IV BD 
    3. Inj. CLINDAMYCIN 
    4. INJ PAN 40 mg IV/OD
    5. INJ. INSULIN -  HAI    6U 6U 6U 
        • NPH  10U X  100
    6. TAB. TELMA 40 /10 RT OD
    7. TAB ECOSPIRIN  150 mg RT /OD 
    8. TAB CLOPIDOGREL 150 mg RT/OD 
    9. TAB ATORVAS  40 mg /RT / OD
    10. INJ OPTINEURON 1 amp 
    11. IVF- NS@ 100 ml per hour 
      • RL 
    12. PHYSIOTHERAPY of left UL and LL 
    13. INJ MANNITOL 100 ml / IV/TID 
    14. Air BED, position change every hour 
    15. GRBS monitoring 6th hourly 
    16. BP PR TEMP monitoring 
    17. THROMBOPHOE ointment for L/A on L arm 
    TREATMENT 26 /7/ 21
    1. RT FEEDS 150 ML WATER 1 HOURLY (200 ML MILK PLUS PROTEIN POWDER 4TH HOURLY 
    2. Inj Monocef 1g IV BD 
    3. Inj. CLINDAMYCIN 
    4. INJ PAN 40 mg IV/OD
    5. INJ. INSULIN -  HAI    6U 6U 6U 
        • NPH  10U X  100
    6. TAB. TELMA 40 /10 RT OD
    7. TAB ECOSPIRIN  150 mg RT /OD 
    8. TAB CLOPIDOGREL 150 mg RT/OD 
    9. TAB ATORVAS  40 mg /RT / OD
    10. INJ OPTINEURON 1 amp 
    11. IVF- NS@ 100 ml per hour 
      • RL 
    12. PHYSIOTHERAPY of left UL and LL 
    13. INJ MANNITOL 100 ml / IV/TID 
    14. Air BED, position change every hour 
    15. GRBS monitoring 6th hourly 
    16. BP PR TEMP monitoring 
    17. THROMBOPHOE ointment for L/A on L arm 

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