Acute CVA

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. 

70 year old female was brought to the casualty with complaints of slurring of speech in morning for 15 minutes at 8am following which patient returned to normal 

No loc, seizure like activity, drooling of saliva,deviation of mouth ,no weakness of limbs,

No H/O Fever; Headache; Giddiness

No H/O Chest pain; orthopnea; sweating, palpitations;, PND.

No H/O Burning Micturition

No H/O loose stools; Nausea, Vomiting

Was treated by local practioner with unknown medications

Patient continued her daily routine cooking,eating

At around 7pm patient developed similar episode lasting for 15 minutes

Was taken to Mothkur for treatment and was given clopidogrel a ,neurobion 

( no investigations were done)

On the way back to the home , patient developed deviation of mouth ,uprolling of eyeballs, dif haficulty in moving lower limbs with decreased responsiveness

Brought to our hospital for further management 

Daily wage labourer ( agriculture)

Stopped working 20years back 

Walking with support from past 3years due to worsening knee pains

2y back- neck pain, giddiness --> diagnosed as hypertension started on medication telma 40

1year increased giddiness diagnosed as cervical spondylosis and prescribed C collar

3-4 months back patient c/o increased giddiness imaging done showing no abnormality 

( no trauma/ recurrent falls)

Past history

K/C/O Hypertension since 10 years (on Telmisaratan 40Mg PO/OD)

Menopause attained 30 years ago.

OBSTERIC HISTORY

   Age of marriage: 13

   Age at first child birth: 14

   Para: 5

   No. of living children: 5

At presentation 

Patient 

Drowsy but arousable 

Concious and cooperative 

Gcs- E2V2M5

Pupils -bilateral Normal size ,reacting to light 

Vitals - 

Bp -110/70 mmHg

Pr- 95bpm regular

Rr- 18cpm

Sat - 100 on RA

Temp - 97F

Moderately built, well nourished

CARDIO VASCULAR SYSTEM

 S1S2 +

RESPIRATORY SYSTEM:

BAE present

Position of Trachea – Central

ABDOMEN

    Shape of abdomen – Obese

    Bowel sounds – Yes

CNS

Hmf - couldn't be assessed 

Gait- couldn't be assessed 

Motor- 

Tone- 

        Rt.     Lt. 

UL  inc.     Inc. 

LL.  Inc.     N

Reflexes- 

        B.     T.    S.     K.    A.   Pl

Rt. +++   ++   ++    ++   ++   Extension 

Lt.  ++   +++  ++    ++   ++  ex-> mute

Response to pain + in left upper limb and lower limb 

Meningeal signs-absent

Carotid bruit  absent

Cvs-s1,s2+, no added murmurs

Rs- bae+,nvbs present

Provisional diagnosis 

Acute stroke ? MCA. ? PCA

MRI done showing acute infarcts in occipital lobes

Fever chart

Chest Xray AP view

ECG

Investigations

Rbs 173

Blood urea 33

Hba1c 6.8

Tb 0.80

Db 0.20

Alkaline phosphatase 250

Albumin 3.1

Serum creat 0.8

Hb 13.1

Fbs 148

Treatment

RT feeds 200ml milk every 4th hourly

100ml water every hourly

IV fluids NS at 500ml/hr

Tab ecospirin AV 75/10mg po od 

Strict input output charting 

16/02/23

ICU-BED NO.2

UNIT 2

73-year-old female came to the casualty with 

c/o slurring of speech since 1 day 

S

One fever spike since yesterday at 9pm 101F

Stools passed 

O

On examination

Patient is concious but drowsy

Temp: afebrile

Bp 140/80mmhg

PR- 102bpm

Grbs 162mg/dl

15/2/23

8 am 170

2pm 147

8pm 147

Spo2- 95%

Input 2400

Output 1700

CARDIO VASCULAR SYSTEM 

 Cardiac Sounds S1S2 +

RESPIRATORY SYSTEM

BAE present, NVBS present 

Per abdomen:

Soft,non tender

Tone: normal in all 4 limbs 

Investigations

Hb 12.7

TLC 10800

PLT 2.43

A

Acute CVA secondary to acute infarct in ?right parietal lobe, B/l cerebellar hemisphere,B/L temporal lobe ,B/L thalamus, pons, midbrain with diffuse cerebral atrophy

k/c/ HTN since 10 years

Denovo DM

Treatment

RT feeds 200ml milk every 4th hourly

100ml water every hourly

IV fluids NS at 500ml/hr

Tab ecospirin 150 mg po od

Tab.clopitab 75 mg po/qid

Tab.Atorvac 40 mg po/hs

Monitor vitals every 2 nd hourly

Grbs charting every 6 th hourly 

Strict input output charting