ACUTE CVA WITH RIGHT OCCIPITAL, THALAMUS AND RIGHT SIDE OF CORPUS COLLOSUM INFARCTS K/C/O HTN SINCE 3 YEARS

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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


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80YR OLD FEMALE WITH C/O LEFT UPPER LIMB AND LOWER LIMB WEAKNESS SINCE YESTERDAY NIGHT.

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC TILL YESTERDAY THEN SHE DEVOLEPED SUDDEN ONSET WEAKNESS OF LEFT UPPER LIMB AND LOWER LIMB.

WEAKNESS IMPROVED COMPARED TO YESTERDAY NIGHT

H/O BLURRING OF VISION PRESENT

NO H/O DEVIATION OF MOUTH

NO H/O SLURRING OF SPEECH

NO H/O INVOULANTARY PASSAGE OF STOOLS OR URINE

NO H/O HEADACHE, GIDDINESS

NO H/O FEVER, LOSS OF CONSCIOUSNESS.

PAST HISTORY:

K/C/O HTN SINCE 3 YEARS ON REGULAR MEDICATION(UNKNOWN)

N/K/C/O DM, CAD, SEIZURES, TB, THYROID DISORDERS AND ASTHMA.

GENERAL EXAMINATION :

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY AND OEDEMA.

AFEBRILE

BP- 130/90 MMHG

PR-86 BPM

RR-18 PM

SPO2 96%

SYSTEMIC EXAMINATION:

P/A: SOFT, NON TENDER,  BOWEL SOUNDS HEARD.

CVS-S1S2 HEARD NO MURMURS.

RS-BAE +

 

MRI BRAIN DONE ON 15/12/23

IMPRESSION:

-ACUTE INFRACT IN RIGHT OCCIPITAL AND LOBE RIGHT SIDE OF CORPUS CALLOSUM.

-OLD LACUNAR INFRACTS IN BILATERAL STRAITO CAPSULAR REGION.


DIAGNOSIS :

ACUTE CVA WITH RIGHT OCCIPITAL, THALAMUS AND RIGHT SIDE OF CORPUS COLLOSUM INFARCTS

K/C/O HTN SINCE 3 YEARS


TREATMENT:

TAB ECOSPIRIN 75mg PO/HS

TAB CLOPIDOGREL 75mg PO/HS

TAB ATORVASTATIN 20mg PO/HS

TAB PAN 40mg PO/OD

TAB CINOD 10mg PO/OD

INJ OPTINEURON 1 AMP IN 100ML NS IV/OD


ADVICE AT DISCHARGE :

TAB ECOSPIRIN 75mg PO/HS

TAB CLOPIDOGREL 75mg PO/HS

TAB ATORVASTATIN 20mg PO/HS

TAB CINOD 10mg PO/OD

PHYSIOTHERAPY

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