57 year old with acute ischemic stroke

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Name: M.Srilekha

Admitted on 19/2/23:

Chief complaints:

Pt was bought to the casuality with complaints of shortness of breath weaknesses of upper and lower limbs slurring of speech difficulty in swallowing since 2:00pm today 

History of presenting illness:

Pt was apparently asymptotic 14years back then he developed SOB chest pain PTCA/stent replacement was done and was on regular follow up for the same 

Today morning while doing his routine activities he developed weakness of left upper limbs lower limbs with slurring of speech difficulty in swallowing 

Sudden in onset non progressive 

not a/w loss of consciousness,Seizure like activity involuntary micturition /bowel incontinence,giddiness,headache,projectile vomiting,fall,head injury

No h/o fever giddiness chest pain palpitations decreased urine output 

Shortness of breath since 20 days 

Insicidious in onset gradually progressing from MMRC 2-MMRC 3/4, orthopnea present, wheeze present, no PND.

H/o fever present not a/w cough /cold.

Past history: 

H/o PTCA done 14 years back 

No similar complaints in the past 

Not a k/c/o HTN,DM,TB,Epilepsy,asthma,cad,CVA 

Personal history:

Appetite lost 

Bowel and bladder regular 

No known allergies 

No addictions

No significant family history 

General examination:

Pt is conscious coherent cooperative  

Well oriented to time place and person 

Vitals:

Pulse rate:76 bpm 

Bp:120/80 mmHg

RR:26 cpm

Spo2:100%at 2 L O2

GRBS:159mg/dl

Systemic examination:

CVS:

S1,S2 heard 

No additional sounds heard 

JVP not raised 

RS:

BAE+, NVBS+

Wheeze present 

Per abdomen:

Soft 

non tender 

Liver palpable

CNS examination:

Conscious 

Speech - slurred

                 Rt                Lt 

Power UL 4/5              0/5

           LL  4/5              1/5

Tone  UL   N             Decreased 

          LL   N              Decreased 

Reflexes biceps triceps supinator knee ankle plantar 

Right     +++      +++        ++           ++    ++ flexibility

Left        +++      +++        ++           ++    ++ extension 

Investigations:

X ray: 

USG done on 20/2/20:

e/o mild pleural effusion 

Impression: Bilateral grade 3  RPD changes 

Mild pleural effusion

Grade 1 fatty liver 

Internal echos notes in urinary bladder ? Cystitis 

ECG:

MRI:

Acute infarct with hemorrhagic transformation right frontal lobe 

2D Echo:

Ejection fraction:29%

moderate MR,mild AR/TR  with PAH

RWMA present RCA akinetic LAD hypokinetic no AS/MS

Severe LV dysfunction present 

Diastolic dysfunction present no PE/NO PAH

ABG

Repeat abg

Provisional diagnosis:

acute ischemic stroke ?right frontal infarct

?cardio embolic stroke 

With heart failure with reduced ejection fraction

With h/o s/p PCTA done 14 years back

Treatment; 

1.Ryles tube 200 ml milk 4 th hourly ,100 ml water 2nd hourly 

2.Tab.ECOSPIRIN AV 75//20/PO/HS

3.Inj.HYDROCORTISONE 100mg/IV/stat

4.O2 supplementation to maintain saturation >94mg/dl

5.Monitor vitals -BP PR RR saturation Temperature hourly, GRBS 4th hourly 

6.Nebulisation with IPRAVENT 8th hourly 

                              BUDECORT -12th hourly 

7.Tab.SACUBITRIL + VALSARTAN PO OD

8.tab.CLOPITAB 75 mg RT/OD