70M with acute Ischemic stroke with DM

DOA: 9/1/2023
Discharge 
Date:16/01/23
Ward:AMC
Unit:GM1
Diagnosis
ACUTE ISCHEMIC STROKE ( ACUTE INFRACT IN RT MIDDLE FRONTAL GYRUS / OPERCULUMINVOLVING RT ACA TERRORITY WITH LT UMN FACIAL PALSY)
DM SINCE 10 YEARS

Case History and Clinical Findings
c/o of slurring of speech and deviation of mouth to the right side since yesterday morning.

HOPI: Patient was apparently asymptomatic 10 years back after which he had a history of a thornprick to the left middle finger which formed a swelling filled with pus.
Patient was diagnosed to have diabetes mellitus, after which his left middle finger was amputated.Since then, the patient is on regular diabetic medication.
H/O of burning sensation and tingling in both lower limbs since 1 year
Patient is having slurring of speech and deviation of mouth to the right side since yesterday morning
No H/O weakness of limbs, seizures, trauma, headache/nausea, or fever.
K/C/O DM type 2 since the last 10 years (on regular medication, Glimi M1)EXAMINATION

Pt is C/C/CBP:130/80mmhg
PR:96bpmRR:20/minGRBS-261
Temp : Afebrile
CVS:S1S2+,Nomurmurs
RS :Bilateral air entry present
Normal vesicular breath sounds heard
PA- soft, non tender, bowel sounds heard
CNS-
Pupils- left- Reacting to light
right- dilated, not reacting to lightHigher mental functions
Conscious
Oriented to time,place and person
Memory - Intact
Speech - slurred
Cranial nerve examination
1 - olfactory sense - normal
•2- visual acuity present
•3,4,6 - no ptosis Or nystagmus
•5- corneal reflex present
•7- deviation of mouth to right side, loss of nasolabial folds on left side
8- Normal hearing
•9,10- position of uvula is central ,Gag reflex- present
•11- sternocleidomastoid contraction present
•12- no deviation of tongue
Motor system
Reflexes
Right LeftBiceps - -Triceps - -Supinator - -Knee. 1+. 1+Ankle. - -
Plantars- Flexion FlexionPower. Lt. Rt
Upper limb -4/5. 4/5
Lower limb -4/5 4/5TONE. Lt. Rt
Upper limbs N NLowerlimbsNN
No Involuntary movements
SENSORY SYSTEM
–SPINOTHALAMIC R L
Crude touch N N
Pain. N. N
Temperature. N. N
–POSTERIOR COLUMN
Fine touch. N. N
Vibration. N. N
Position sense. N. N
Romberg’s sign -EquivocalIII –CORTICAL
Two pointdiscrimination.N.N
Tactile localisation. N. N
Graphaesthesia. N. N
Stereognosis. N. NCEREBELLAR TestsNo Nystagmus
Finger Nose test - normalHeel Knee test - normalDysdiadokokinesia-normal

Investigation
CT SCAN BRAIN : NO E/O ANY HEMORRHAGES IN BRAIN
HYPO DENSE AREA IS SEEN IN RIGHT FRONTAL AREA LIKELY INFRACTUSG ABDOMEN : CHOLELITHIASIS
LEFT MILD HYDRONEPHROSISGRADE 1 PROSTAMEGALY
2D ECHO : AORTIC VALVE CALCIFIED, THICKENEDRIGHT ATRIUM AND VENTRICLE NORMAL
LEFT ATRIUM : 3.4 CM
LEFT VENTRICLE : CONCENTRIC LVH ,NO RWMAEDD: 5.17 EF : 58 %
CONCLUSION : MODERATE AR, TRIVAL AR NO MR, NO RWMA, MODERATE AS+, NO MSDIASTOLIC DYSFUNCTION + NO PAH/PE

Treatment Given(Enter only Generic Name)INJ OPTINEURON 1 AMP IN 500 ML/NS IV ODINJ LEVIPIL 500 MG IN 100 ML NS IV BD
TAB ECOSPIRIN 75 MG RT/ODTAB ATORVAS 40 MG RT/HSSYPLACTULOSE15MLRT/HS

Advice at Discharge
TAB.LEVIPILL 500MG PO/BD X1WEEKTAB.ECOSPIRIN75MGPO/ODHSX1WEEK
TAB.ATORVAS 40MG PO/OD HSX1WEEKTAB.METFORMIN 500MG PO/ODPHYSIOTHERAPY OF FACIAL MUSCLESSMOKING AND ALCOHOL ABSTINENCE

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