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.

Popular posts from this blog

49F DM with Uncontrolled Sugars

Image
 A 49 years old Female who is a house wife by occupation came with C/O  Fever since 15 days  Patient was apparently asymptomatic 9 years back then she started having bleeding per vagina for which she went to hospital & Diagnosed to have ? Fibroid uterus for which she went to a private hospital in hyderabad for hysterectomy as advised in local hospital. Then she had high sugars for the first time (Around 450mg/dl).So she was admitted in the hospital & hysterectomy was done after controlling the sugars with Insulin.Then she was discharged with Tab.GLIME M1 PO BD & continued the tablet for 3 years along with diabetic diet. Then she came to our OP for Follow then she was prescribed with Tab.GLIME M2 PO BD which she used for 2 years. Then she came to our OP for Follow up then she was escalated to Tab.GLIME M3 PO BD. March 2023 She had ulcer over left great toe for which she was admitted in our hospital & got relieved. November 2023  She had Swelling of Rt....
Read more

70M CKD Sec to RVD

Image
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT  A 70 year old Male Who was a Farmer by Occupation  came to OPD with C/O  B/L Knee Pains & LBA Since 10 days SOB ; B/L Pedal Edema Since 1 Week  Vomitings Since 3 days  HISTORY OF PRESENTING ILLNESS: Pt Was Apparently Asymptomatic 20 years back and developed Fever for which he went to Hospital and Informed that he has ? Renal Problem for which he Used Some ? Medication for 1 Year & Then He was Fine.5 years Back he was Diagnosed with RVD & Started Using ART. Then He was Fine & 10 Days Back he Started Having B/L Knee Joint Pains & LBA for which He...
Read more

48F DM Uncontrolled Sugars ; Lt.Great Toe Amputation

Image
 A 48 years old female resident of Vellemla (Narketpally Mandal) who is a home maker came to Casualty with complaints of  Wound Over Lt Foot Since 1 week  Patient Was apparently asymptomatic 8 years back then developed generalized weakness for which she went to hospital & diagnosed to have DM for which she started using medication TAB.METFORMIN 500MG PO/OD & TAB.GLIMEPERIDE 1MG PO/OD. She was using tablets regularly. In b/w she visited our hospital for 2-3 times then her ?FBS - was <250.  February 2024 She developed a fluid filled bleb over her Lt. Great toe which ruptured Spontaneously & healed after dressing done at local hospital. No H/O of Fever at that time. 10th April 2024  She developed a Wound Near Lt.Great toe associated with Swelling of Lt.LL & fever for which she came to our OPD. Advised for admission but they denied admission Investigations on 10/04/24 :  Hb - 9.4 ; TLC - 23900 ; PLT - 3.65 RBS - 604 ; HbA1C : 8.2% S.Creatinin...
Read more