Case 34 56 Male with altered sensorium since 3 days

Doa 18/12/23

Dod 20/12/23

Diagnosis

RECURRENT CVA WITH ACUTE INFARCT IN LEFT , K/C/O TYPE -II DIABETES

MELLITUS.HYPERTENSION.

Case History and Clinical Findings

A 55 YEAR OLD MALE CAME TO THE CASUALITY WITH THE COMPLAINTS OF ALTERED

SENSORIUM SINCE 3 DAYS, SLURRING OF SPEECH SINCE3 DAYS,DIFFICULTY IN WALKING

SINCE 3 DAYS. PATIENT WAS EVALUATED CLINICALLY AND WITH APPROPRIATE

INVESTIGATIONS WAS PROVISIONALLY DIAGNOSED ASRECURRENT CVA WITH ACUTE

INFARCT IN LEFT? BASAL GANGLIA , K/C/O TYPE -II DIABETES MELLITUS.HYPERTENSION.

PATIENT IS A K/C/O TYPE-II DM AND HYPERTENSION SINCE 15 YEARS, K/C/O CVA WITH

RIGHT HEMIPARESIS -4 YEARS AGO.THE HAEMOGRAM WAS NORMAL.

THE PT WAS STARTED ON CONSERVATIVE MANAGEMENT ( TAB. ECOSPIRIN 75 MG PO OD,

TAB.CLOPIDOGREL 75 MG PO OD, TAB.ATORVASTATIN 20 MG PO OD, TAB.VILDAGLIPTIN 80

+ METFORMIN 500 MG PO OD, TAB.TELMIKIND-H 40/125 PO OD, INJ. THIAMINE 200 MG IN 100

ML NS IV OD, INJ. OPTINEURON 1 AMP IN 100 ML NS IV OD , TAB. LEVIPIL 500 MG PO OD)

GENERAL EXAMINATION-

THE PATIENT IS CONSCIOUS, COHERENT, COOPERATIVE

MODERATELY BUILT AND NOURISHED

NOPALLOR, ICTERUS, CYANOSIS, CLULBBING, EDEMA

VITALS:

TEMP: 96.8 F

PR: 98 BPM

RR: 18 CPM

BP: 110/70 MM HG

SPO2: 98% @ RA

GRBS: 110 MG/DL

CVS: S1, S2 HEARS, NO MURMURS

RS: BAE+, NVBS

TRACHEA: CENTRAL

NO DYSPNOEA AND WHEEZE

NO RHONCHI

ABDOMEN:SOFT, NON-TENDER, NO ORGANOMEGALY.

LIVER AND SPLEEN NOT PALPABLE

BOWEL SOUNDS .HEARD

CNS:

LEVEL OF CONSCIOUSNESS: CONSCIOUS, ALERT

SPEECH: NO RESPONSE

NECK STIFFNESS ABSENT

KERNINGS SIGN ABSENT

CRANIAL NERVES: CANNOT BE ELICITED

SENSORY SYSTEM: CANNOT BE ELICITED

GCS: 11/15 E4V1M6

MOTOR SYSTEM:

TONE:

UL:NORMAL IN BOTH

LL: NORMAL IN BOTH

POWER:

UL: BOTH 5/5

LL: BOTH 5/5

REFLEXES: RT LT

B: +3 +3

T: +3 +3

S: +2 +2

K: +3 +3

A: +2 +2

EXTENSOR PLANTAR RESPONSE.

CEREBELLAR SIGNS CANNOT BE ELICITED.

Investigation

NameValueRangeNameValueRangeHBsAg-RAPID18-12-2023 07:56:PMNegative Anti HCV

Antibodies - RAPID18-12-2023 07:56:PMNon Reactive BLOOD UREA18-12-2023 07:56:PM14

mg/dl42-12 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 18-12-

2023 07:56:PMSODIUM139 mEq/L145-136 mEq/LPOTASSIUM4.0 mEq/L5.1-3.5

mEq/LCHLORIDE99 mEq/L98-107 mEq/LCALCIUM IONIZED1.17 mmol/Lmmol/LRFT 18-12-2023

07:56:PMUREA14 mg/dl42-12 mg/dlCREATININE0.9 mg/dl1.3-0.9 mg/dlURIC ACID3.0 mg/dl7.2-3.5

mg/dlCALCIUM10.0 mg/dl10.2-8.6 mg/dlPHOSPHOROUS3.8 mg/dl4.5-2.5 mg/dlSODIUM139

mEq/L145-136 mEq/LPOTASSIUM4.0 mEq/L5.1-3.5 mEq/LCHLORIDE99 mEq/L98-107

mEq/L FBS 353 mg/dl PLBS 387 mg/dl Hba1C 8.4 LIVER FUNCTION TEST (LFT) 18-12-2023 07:56:PMTotal Bilurubin0.70 mg/dl1-0 mg/dlDirect

Bilurubin0.17 mg/dl0.2-0.0 mg/dlSGOT(AST)21 IU/L35-0 IU/LSGPT(ALT)25 IU/L45-0 IU/LALKALINE

PHOSPHATE183 IU/L128-53 IU/LTOTAL PROTEINS7.3 gm/dl8.3-6.4 gm/dlALBUMIN4.22 gm/dl5.2-

3.5 gm/dlA/G RATIO1.37

MRI PLAIN BRAIN:-

IMPRESSION:-

DIFFUSE CEREBRAL ATROPHY

CHRONIC SMALL VESSEL ISCHAEMIA

OLD LACUNAR INFARCTS IN LEFT STRIATOCAPSULAR REGION AND BILATERAL CENTRUM

SEMIOVALE.

Treatment Given(Enter only Generic Name)

TREATMENT GIVEN AS PER DISCUSSED BY PHYSICIAN

Advice at Discharge

PT AND HIS ATTENDERS HAVE BEEN EXPLAINED ABOUT THE CONDITION OF THE PATIENT

THAT IS RECURRENT CVA WITH ACUTE INFARCT IN K/C/O TYPE -II DIABETES

MELLITUS,HYPERTENSION.AND THE COMPLICATION ASSOCIAED WITH PT CONDITION HAS

BEEN EXPLAINED . THE NEED FOR ADMISSION AND FURTHER EVALUATION HAS BEEN

EXPLAINED BUT PT ATTENDERS ARE NOT WILLING AND WANT TO GO ON LAMA DISPITE

EXPLAINIG THE POSSIBLE RISKS

THE HOSPITAL MANAGMENT,STAFF,DOCTORS ARE NOT RESPONSIBLE FOR UNTOWARD

EFFECTS OUTSIDE

ADVICE AT DISCHARGE

TAB. ECOSPIRIN 75 MG PO OD

TAB.CLOPIDOGREL 75 MG PO OD

TAB.ATORVASTATIN 20 MG PO OD

TAB.VILDAGLIPTIN 80 + METFORMIN 500 MG PO OD

TAB.TELMIKIND-H 40/125 PO OD

INJ. THIAMINE 200 MG IN 100 ML NS IV OD

INJ. OPTINEURON 1 AMP IN 100 ML NS IV OD

TAB. LEVIPIL 500 MG PO OD