CEREBRO VASCULAR ACCIDENT(CVA)......ELOG BY SAI PRANEETH BATHINEEDI

 GENERAL MEDICINE CASE PRESENTATION; 

4\7\21;

SAI PRANEETH BATHINEEDI;
ROLL NO 116;
3 SEM STUDENT;
        

NEUROLOGY ;

A CASE OF LEFT SIDED CVA(CEREBRO VASCULAR ACCIDENT)INVOLVING MCA TERRITORY;


A 55 years old man came to OPD with chief complaints of slurring of speech and inability to swallow any solids or liquids since 4 days & also C\O deviation of mouth to he right side along with inability to walk since 4 days;


HISTORY OF PRESENTING ILLNESS;
The patient was apparently asymptomatic 20 months back when he had symptoms deviation of mouth(not sure which side) and weakness of limbs for which he was diagnosed as a case of  ?TIA(TRANSIENT ISCHAEMIC ATTACK)for which he was admitted in that hospital for a week and eventually he was also developed as a case active pulmonary kochs -He was on ATT(ANTI TUBERCULOSIS TREATMENT) regimen for 6 months;

On 30\7\21 patient came with C\O slurring of speech ;
C\O  deviation of mouth to right side along with drooling of saliva from the mouth;
C\O inability to swallow solids \liquids since last 4 days;
C\O generalized weakness started 4 days back which worsened at present and unable to walk without support as described by the attendents;

PAST HISTORY;
K\C\O TB DIAGNOSED 20 MONTHS BACK FOR WHICH HE UNDERWENT ATT REGIMEN FOR 6 MONTH;
H\O ?CVA 1 YEAR AGO;
NOT K\C\O DM ,EPILEPSY AND HYPERTENSION;

PERSONAL HISTORY;
DIET-Mixed;
APPETITE-Decreased;
SLEEP -Adequate;
BOWEL AND BLADDER MOVEMENTS-Normal;
CHRONIC SMOKER SINCE 30 YEARS(30  Beedis\day);
REGULAR ALCOHOL CONSUMPTION(90ml\day);
AGGRESSIVE BEHAVIOUR;

FAMILY HISTORY;
NO SIGNIFICANT HISTORY;

GENERAL EXAMINATION;
Patient is conscious with slurred speech,moderately built and moderately nourished;
NO Pallor,Icterus,cyanosis,clubbing,lymphadenopathy and edema;

VITALS;
BP:110\70MM OF HG;
PR:80BPM
RR:18 TIMES PER MINUTE;
SPO2:96% AT ROOM AIR;
AFEBRILE;

SYSTEMIC EXAMINATION;
RESPIRATORY SYSTEM:NVBS Heard, BAE Present;
CVS:S1,S2 Heard ,NO Murmur ,No Thrills;
PER ABDOMEN :Soft, Non tender, Bowel Sounds Heard;
CNS: Patient has Dysarthria;
Deviation of mouth to right side, Inability to swallow;
Tone is increased in B\L Upper and Lower limbs;
REFLEXES ;
RT   LT
2+      2+   - BICEPS
2+       2+   -TRICEPS
2+        2+   -SUPINATOR
-            +   -KNEE
-             +  -ANKLE
TONE; U\L  NORMAL -RT, DECREASED-LT
L\L NORMAL-RT,MILD-LT
POWER B\L 3\5;
FASCICULATIONS PRESENT;

INVESTIGATIONS;
MRI BRAIN;
1) ACUTE INFARCT INVOLVING RIGHT TEMPORAL AND PARIETAL LOBES- MCA(MIDDLE CEREBRAL ARTERY)TERRITORY
2)OLD INFARCT INVOLVING INFERIOR ASPECT OF LEFT CEREBELLAR HEMISPHERE
3)OLD LACUNAR INFARCT IN LEFT THALMUS

DIAGNOSIS;LEFT SIDED CVA WITH ACUTE INFARCT IN MCA TERRITORY INVOLVING RIGHT PARIETAL AND TEMPORAL LOBE

CLINICAL RELEVANT DATA OF THE PATIENT ;
MRI OF THE PATIENT;




MRI FINDINDGS;
TREATMENT ;
ON 1\7\21;
1)RT FEEDS WITH 100 ML MILK 2ND HOURLY AND 100 ML WATER HOURLY;
2)INJ PAN 40 MG IV\OD;
3)INJ OPTINEURON 1 AMP IN 100ML NS\IV OVER 30 MINUTES;
4)PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE;
5)TAB. CLOPIDOGREL 75MG RT\OD;
6)TAB. ASPIRIN 150MG RT\OD;
7)TAB. ATORVAS 40 MG RT\OD;
8)INJ. MANNITOL 100 ML IV\TID;

ON 2\7\21;
1)RT FEEDS WITH 100 ML MILK 2ND HOURLY AND 100 ML WATER HOURLY;
2)INJ PAN 40 MG IV\OD;
3)INJ OPTINEURON 1 AMP IN 100ML NS\IV OVER 30 MINUTES;
4)PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE;
5)TAB. CLOPIDOGREL 75MG RT\OD;
6)TAB. ASPIRIN 150MG RT\OD;
7)TAB. ATORVAS 40 MG RT\OD;
8)INJ. MANNITOL 100 ML IV\TID;

ON 3\7\21;
1)RT FEEDS WITH 100 ML MILK 2ND HOURLY AND 100 ML WATER HOURLY;
2)INJ OPTINEURON 1 AMP IN 100ML NS\IV OVER 30 MINUTES;
3)PHYSIOTHERAPY OF LEFT UPPER LIMB AND FACE;
4)TAB. CLOPIDOGREL 75MG RT\OD;
5)TAB. ASPIRIN 150MG RT\OD;
6)TAB. ATORVAS 40 MG RT\O
7) BP MONITORING 4TH HOURLY;

ECG;NORMAL SINUS RHYTHM;






COMPLETE BLOOD PANEL;


ADVICE AT DISCHARGE;
1)TAB. ASPIRIN 150 MG\RT\OD AT 2PM;
2)TAB. CLOPIDOGREL RT\OD AT 9PM;
3)TAB. ATORVAS 40 MG\RT\OD AT 9PM;
4)TAB. ZIRCOVIT RT\OD;
5)PHYSIOTHERAPY OF LEFT UPPERLIMB;

AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE;
TAKE MEDICATIONS ON A REGULAR BASIS;
TAKE THE PATIENT FOR FREQUENT COUNSELLING SESSIONS TO GET RID OF SMOKING AND DRINKING;

AT LAST I WOULD LIKE TO THANK THE ENTIRE GENERAL MEDICINE DEPARTMENT(RAKESH BISWAS SIR HOD) AND CHITRA MAAM(INTERN)FOR HELPING ME TO GATHER THE INFORMATION AND SUCCESSFULLY COMPLETING THIS BLOG😃😃😃





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