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