54F CVA DM2

Admission Date : 2/06/22
Discharge Date
Date:6/6/22
Ward:GENERALMEDICINE
 Unit:UNIT III

Diagnosis :
ISCHEMIC STROKE 
RIGHT HEMIPLEGIA 
INFARCT IN LEFT PUTAMEN, LEFT CAUDATE AND LEFT MIDDLE CEREBRAL ARTERY TERITORY INFARCT

Case History :
PATIENTWASAPPARENTLYASYMPTOMATICON1/6/22ANDTHENHEHADH/OALTERED SENSORIUM ON 1/6/22 9 AM.
H/ODIFFICULTYINWALKINGINTHEMORNING H/O LOSS OF SPEECH 6 AM IN THE MORNING
H/OWEAKMESSOFTHERIGHTUPPERLIMBANDLOWERLIMBIN9PMINTHEEVENING NO H/O HEADACHE , FEVER , VOMITING, CHEST PAIN , PALPITATIONS, SHORTNESS OF BREATH.
NO OTHER COMPLAINTS
K/C/OHTNANDWASONANTIHTNMEDICATIONS-TABCLINIDIPINE10MGANDTAB METAPROLOL 50 MG AND TAB TELMA 40 MG
K/C/O DM AND WAS ON OHA ON TAB DAPAGLIPTIN 10 MG AND TAB METFORMIN 500 MG PATIENTISUSINGCINNARIZINEANDDIMENHYDRINATEPROCHLORPERAZINEMALEATE NO SIGNIFICANT FAMILY AND PERSONAL HISTORY.
GENERALEXAMINATION:PATIENTISCONCIOUS,COHERENT,COOPERATIVE. NO PALLOR, CYANOSIS, CLUBBING, LYMPHADENOPATHY, EDEMA TEMPERATURE - AFEBRILE


PULSERATE-77BPM RR - 22 CYCLES / MIN BP - 170/90 MMHG SPO2 - 94 % @ RA GRBS - 92 MG/DL
SYSTEMIC EXAMINATION :
CVS-S1S2HEARD RS- BAE+
ABDOMEN-SCAPHOID,NOABNORMALITIES. CNS- LEVEL OF CONCIOUSNESS- DROWSY SPEECH - APHASIC
NOMENINGEALSIGNS RIGHT LEFT
TONE:U/LDECREASEDNORMAL L/L DECREASED NORMAL POWER 0/5 4/5
REFLEXES:BICEPSTRICEPSSUPINATORKNEEANKLE RIGHT - -- - - -
LEFT +2 +2 +2 +2 +2
PLANTAR-RIGHT-EXTENSOR LEFT - FLEXOR
CEREBRALSIGNS-UNABLETOEXAMINE. GAIT - UNABLE TO EXAMINE.

Investigation
MRI-INFARCTINLEFTPUTAMEN,LEFTCAUDATEANDLEFTMIDDLECRANIALARTERY TERITORY INFARCT
Treatment Given(Enter only Generic Name)
IV FLUIDS - NS @50 ML/HR
RT FEEDS 250 ML MILK WITH TWO TABLE SPOONS PROTIEN POWDER
100 ML WATER EVERY 2ND HOURLY.
INJ MANNITOL 100 ML IV/BD
INJ MONOCEF 1 GM/IV/BD
TAB ECOSPIRIN 150 MG / PO/HS X - X - 1


TAB ATORVAS 40 MG / PO/HS X- X - 1
TAB MET- XL 50 MG / PO/OD 1 - X-X
TAB AMLONG 5 MG /PO/OD 1 - X -X
TAB PAN 40 MG /PO/OD 1 - X-X
INJ HUMAN ATROPID INSULIN ACCORDING TO GHECK GRBS INFORM
BP MONITORING 4TH HOURLY.
STRICT INPUT/OUTPUT CHARTING
TAB DOLO 650 MG PO/QID
OINT THROMBOPHOBE FOR L/A
TAB AZITHROMYCIN 500 MG RT/OD
INJ AUGMENTIN 1.2 GM / IV/BD
17TAB ZINCOVIT /RT/OD
18 INJ CITICHOLINE 500 MG/IV/ IN 1000 ML NS BD
19 INJ PIRACETAM 800 MG IV/ IN 1000 ML NS
19 NEB WITH DOU;LIN AND BUDECORT I REPSULE 8TH HOURLY.

Advice at Discharge :
LAMA-PATIENTATTENDERSHAVEBEENEXPLAINEDABOUTPATIENTCONDITIONANDITS COMPLICATIONS DESPITE THEY ARE NOT WILLING FOR FURTHER MANAGEMENT AND HOSPITAL STAY.

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