45M with posterior circulation stroke with DM type 2

DOA - 2/2/2023
Discharge Date
Date: 8/2/23
Ward: MEDICAL WARD
Unit: GM IV

Diagnosis
POSTERIORCIRCULATIONSTROKEWITHACUTEINFARCTINLEFTMEDULLAANDINFERIOR CEREBELLAR HEMISPHERE.HEPATITIS B POSTIVE SINCE 3 YEARS WITH KNOWN CASE OF DIABETES MELLITUS TYPE II SINCE 10 YEARS (ON ORAL HYPOGLYCEMIC DRUGS)
Case History and Clinical FindingsCOMPLAINTS OF GIDDINESS SINCE 1 DAY COMPLAINTSOFDOUBLEVISIONSINCEMORNING
COMPLAINTS OF DIFFICULTY IN SWALLOWING SINCE MORNING COMPLAINTSOFWEAKNESSOFLEFTLOWERLIMBANDINABILITYTOWALK

HOPI:
PATIENTWASAPPARENTLYASYMPTOMATICTILLYESTERDAYTHENHEHAD1EPISODEOF VOMITING - FOOD PARTICLES AS CONTENT, NON PROJECTILE, NON BILIOUS, NON BLOOD STAINED
INTHEEVENINGHEDEVELOPEDGIDDINESSWHICHHETHOUGHTWASHYPOGLYCEMIC EPISODE AND HAD A COOL DRINK.


THEGIDDINESSDIDN'TSUBSIDESOHEWENTTOALOCALRMPANDFOUNDTOBEHAVING SBP OF 90 MMHG AND HENCE FLUIDS WERE GIVEN AND SENT HOME.
ATAROUND5AMHECOULDN'TGETUPANDHENOTICEDWEAKNESSOFLEFTLOWER LIMB AND EXPERIENCED SEVERE GIDDINESS AND WAS TAKEN TO A LOCAL HOSPITAL WHERE MRI WAS DONE.
ITWASFOUNDTHATHEHADACUTEINFARCTSINLEFTMEDULLAANDINFERIOR CEREEBLLAR HEMISPHERES.
HEALSODEVELOPEDDIFFICULTYINSWALLOWING(SOLIDS>LIQUIDS)ANDDIPLOPIAAND WAS REFERRED HERE FOR FURTHER MANAGEMENT

PAST ILLNESS:
KNOWN CASE OF DIABETES MELLITUS TYPE II SINCE 10 YEARS (ON OHA)
OPERATEDFOR?APPENDICITIS3YEARSAGOANDCOLOSTOMYWASPLACEDFOR3 MONTHS AND WAS DIAGNOSED AS HBSAG POSITIVE AND NOT ON MEDICATION
NOT A KNOWN CASE OF HTN, ASTHMA, CAD, CVD


PERSONAL HISTORY:
DIET- MIXED
APPETITE- DECREASED
BOWELANDBLADDERMOVEMENTS-REGULAR SLEEP- ADEQUATE
ADDICTIONS-ALCOHOLICSINCE3YEARS(250MLBRANDY) CIGARETTE SMOKING SINCE 15 YEARS
KHAINI CHEWING SINCE 20 YEARS


ON EXAMINATION AT ADMISSION:
PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE
NOPALLORICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDALEDEMA BP- 90/60MMHG
PR-59BPM RR-18CPM
SPO2- 98%@RA GRBS-283MG/DL 
CVS-S1 S2 +
RS- BAE+
PA-SOFTNONTENDER CNS-
GCS- E4V5M6
TONEOFBOTHUPPERANDLOWERLIMBS-NORMAL POWER
RTUPPERLIMB-5/5 LTUPPERLIMB-4/5 RTLOWERLIMB-5/5 LT LOWERLIMB- 4/5 REFLEXES-
RIGHT LEFT BICEPS + ++ TRICEPS + ++ SUPINATOR++++ KNEE + +
ANKLE - -
PLANTAR FLEXOR FLEXOR
GAIT- COULDN'T BE ELICITED

EXAMINATION AT DISCHARGE:
PATEINT IS CONSCIOUS, COHERENT, COOPERATIVE
NOPALLORICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDALEDEMA BP- 90/60MMHG
PR-78BPM RR-17CPM
SPO2- 98%@RA GRBS-249MG/DL CVS-S1 S2 +
RS- BAE+
PA-SOFTNONTENDER CNS-
GCS- E4V5M6


TONEOFBOTHUPPERANDLOWERLIMBS-NORMAL POWER
RTUPPERLIMB-5/5 LTUPPERLIMB-4/5 RTLOWERLIMB-5/5 LT LOWERLIMB- 4/5 REFLEXES-
RIGHT LEFT BICEPS + ++ TRICEPS + ++ SUPINATOR-- KNEE - - ANKLE - -
PLANTAR FLEXION FLEXION


BRIEF COURSE IN HOSPITAL
PATIENT CAME WITH ABOVE COMPLAINTS WAS STABILISED BY GIVING T. ECOSPRIN 75MG,
T.CLOPITAB75MG,T.ATORVAS10MG.ONINVESTIGATIONSHEWASTESTEDPOSITIVE FOR HBSAG AND HIS OUTSIDE MRI SHOWED POSTERIOR CIRCULATION STROKE WITH ACUTE INFARCTS IN LEDT MEDULLA AND INFERIOR CEREBELLAR HEMISPHERE. ANTIPLATELET DRUGS AND STATINS WERE CONTINUED.
HE WAS REFERRED TO OPHTHALMOLOGIST ON 2/2/23 IN VIEW OF RAISED ICT AND ANISOCORIAANDADVISEFOLLOWED.ASHEWASKNOWNCASEOFDIABETESANTI DIABETIC MEDICATION WAS CONTINUED. FOR GIDDINESS INJ PROMETHAZINE WAS ADMINISTERED.
WITHADEQUATETREATMENTPATIENTCONDITIONIMPROVEDANDISBEINGDISCHARGED IN HEMODYNAMICALLY STABLE CONDITION
Investigation HEMOGRAMON2/2/23 HB- 14.7GM/DL
TLC- 12,300 CELLS/CUMM
PLATELETS- 2.6 LAKHS/CUMM
IMPRESSION- NORMOCYTIC NORMOCHROMIC WITH LEUKOCYTOSIS


HEMOGRAMON4/2/23 HB- 15GM/DL
TLC- 10,200 CELLS/CUMM
PLT- 2.3 LAKHS/CUMM
IMP- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE


HEMOGRAMON5/2/23 HB- 15.4GM/DL
TLC- 7400 CELLS/CUMM
PLT- 2.09 LAKHS/CUMM
IMP- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE


HEMOGRAMON6/2/23 HB- 15GM/DL
TLC- 6100 CELLS/CUMM
PLT- 1.97 LAKHS/CUMM
IMP- NORMOCYTIC NORMOCHROMIC BLOOD PICTURE


LIPID PROFILE:
TOTALCHOLESTEROL-147MG/DL TRIGLYCERIDES- 180MG/DL
HDL- 38MG/DL LDL- 97MG/DL VLDL-37.8MG/DL

TROPONIN-I - 3834PG/ML


2D ECHO:
TRIVIALTR NO MR/AR NO RWMA
TRIVIAL TR, NO MR/AR
NO AS/MS, SCLEROTIC AV


GOODLVSYSTOLICFUNCTION NO DIASTOLIC DYSFUNCTION NO PAH/PE

REVIEW2DECHOON4/2/23 NO RWMA
TRIVIAL TR, NO MR/AR
NO AS/MS, SCLEROTIC AV
EF=60,GOODLVSYSTOLICFUNCTION NO DIASTOLIC DYSFUNCTION
NO PAH/PE


USG- ABDOMEN GRADEIIFATTYLIVER
Treatment Given(Enter only Generic Name)
RTFEEDS-100MLMILK4THHOURLY 50ML WATER 2ND HOURLY T.ECOSPRIN 75MG RT OD
T. CLOPITAB 75MG RT OD
T. ATORVAS 10MG RT HS
T. BACLOFEN10MG RT OD
INJ PROMETHAZINE 25MG IM BD
INJHUMANACTRAPIDINSULINSCTIDACCTOSLIDINGSCALE INJ PAN 40MG IV OD
INJ ZOFER 4MG IV BD

Advice at Discharge
T.ECOSPRIN GOLD 75MG PO OD
T. PROMETHAZINE 25MG PO BD
T. GLIMI M1 PO OD
T. BACLOFEN 10MG PO OD
T. METFORMIN 500MG PO OD

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