80 yrs old Male came to casualty with
C/O loss of consciousness (for half an hour)
C/O involuntary bowel and bladder incontinence and slurred speech since 4am today(19/12/21)
HOPI
Patient was apparently asymptomatic till 4:00am today got up from bed and walked to washroom ,while walking near the door at 4:00am,patient slipped and fell on the ground-sustained injury to back and head.
He had loss of consciousness for half an hour and then regained.Conscious spontaneous with no involuntary movements,froth from mouth.
H/O involuntary micturition and defecation present
H/O slurred speech present after fall
On presentation patient is conscious,confused,slurred speech present.
Past history
N/K/C/O HTN,DM,TB,epilepsy,CVA,CAD
Personal history
Diet -mixed
Appetite-normal
Bowel movements-irregular
He is a toddy drinker and smokes chutta
Family history
Not significant
General examination
Pt is conscious
Vitals
Temp-Afebrile
Bp-120/60mmHg
PR-90bpm
Spo2-99% on RA
Systemic examination
CVS-S1,S2 +
RS- BAE+,NVBS
P/A-soft,non tender
CNS-
He is conscious and confused
Speech is slurred
Motor examination
Tone -increased on rt side
Reflexes-
Rt. Lt
B. 2+. +
T. 2+. +
S. 2+. +
K. 3+. +
A. 3+. +
Planters-B/L mute
Sensory examination
Flexion movement to pain
Provisional diagnosis
Acute ischemic stroke - secondary to acute infarct in right frontal and parietal region with ? Denovo DM -2
Investigations
On 20/12/21
CBP
Treatment
1. Inj. Mannitol 100 ml IV/STAT
2. Inj. Lasix 80 mg IV/STAT
3. Inj. Actrapid 10U in 25%D over 45min
4. Inj. Labetalol 20 mg IV/STAT
5. Neb with salbutamol 2respules
6. Tab. Ecospirin 150 mg po/stat
7. Tab. Atorvas 40 mg po/HS
8. Bp monitoring 2nd hourly
9. Grbs-6th hourly
10. I/O charting
Soap notes.
21/12/21
Pt is drowsy , but arousable to deep painful stimulus
Gcs - E3V2M4
Temp- 98.7f
Bp- 140/90mmhg
PR - 100bpm
RR- 18cpm
Spo2- 97% at room air
Grbs-120mg/dl
I/0- 1550/1450ml
Rs -bae+
Cvs- s1s2+
P/a- soft , bs+
Cns- pupils lt eye underwent cataract surgery, Rt eye sluggish reacting to light
Corneal conjuctival- present b/l
Dolls eye- present
Tone-
Rt. Lt
Ul. N Dec
LL. Dec. dec
Power
Rt. Lt
UL. 3/5. 3/5
LL. 2/5. 2/5
Reflexes
Rt. Lt
Biceps - -
Triceps - -
Supinator- -
Knee- -
Ankle. - -
Plantar flexors. Flexors
A-
Acute ischemic stroke ( lacunar infract in Rt frontal and occipitotemporal lobe)
Chronic infracts in Rt lentiform nucleus
Denovo HTN
H/0 chronic smoker and alcoholic
P-
Rt feeds 100ml milk protein followed by 50ml free water 4th hrly
Ivf NS RL @ 75ml/hr
Tab ecosporin 75Mg po od
Tab atorvastatin 20mn po od
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