CVA case
General Medicine E-log
A 65 year old male presented to the OPD with slurring of speech and inability to swallow since 4 days.
Chief complaints:
The patient (65, M) came to the hospital with chief complaints of slurring of speech and inability to swallow since 4 days.
History of present illness:
Patient was apparently asymptomatic 20 months ago, when he was admitted after he suffered a ?Transient ischaemic attack (TIA). Patient's family describe the symptoms as weakness of limbs and deviation of mouth (they were not sure which side).
He was admitted in a hospital in Hyderabad for 1 week. Medical records regarding reason for admission are not available. During this week, he was diagnosed to be an active case of Pulmonary koch's, for which he was on ATT for 6 months.
4 days back, patient developed weakness of limbs and slurred speech. He has been unable to walk and was also unable to swallow (solids and liquids) during these 4 days. He also has deviation of tongue to the right side.
Past history:
Patient is a known case of TB since 18 months (1 and a half year) and was on ATT for 6 months.
He also has history of suffering a CVA 12 months (1 year) ago.
Not a known case of DM, HTN, asthma, epilepsy, thyroid disorders.
Personal history:
Patient is a chronic smoker since past 40 years, consumption of about 30 beedis per day.
He continued to smoke even after being diagnosed with TB.
He also regularly consumes alcohol, about 90ml per day.
Patient's family describe him as a person with an aggressive personality.
Family history:
No significant family history.
General examination:
Patient is conscious and coherent.
No pallor, icterus, cyanosis, clubbing, koilonychia, lymphadenopathy and edema is seen.
Vital signs:
BP: 140/90 mmHg
PR: 80 bpm
RR: 18
Temperature: afebrile
SPO2: 96%
Systemic examination:
CNS:
Speech: slurred (dysarthria is present)
Tone: Right Left
UL: increased increased
LL: increased increased
Power: UL: 3/5
LL: 3/5
Reflexes: Right Left
Biceps: 2+ 2+
Triceps: 2+ 2+
Supinator: 2+ 2+
Knee: - +
Ankle: + +
Plantar: bilateral increased
Fasciculations are present.
CVS:
S1, S2 were heard
No murmurs
No thrills
Respiratory system:
Trachea: central
BAE: Present
NVBS heard
No added sounds are heard.
Per abdomen:
Soft, non tender
Bowel sounds: heard
No palpable masses
Investigations:
MRI
Impression:
1. Acute infarct involving right temporal and parietal lobes - MCA territory.
2. Old infarct involving inferior aspect of left cerebellar hemisphere.
3. Old lacunar infarct in left thalamus.
ECG
CBP, RFT, LFT, Lipid profile results
2D Echocardiograph
Treatment given:
30/06/21
1. Dual Antiplatelets
2. BP monitoring
3. Physiotherapy
1/07/21
1. RT FEEDS with 100ml milk 2nd hourly and 100ml water hourly.
2. Inj. PAN 40mg IV/PD
3. Inj. OPTINGURON 1amp in 100ml NS/IV/over 30 minutes
4. Physiotherapy of left upper limb and face
5. Tab. ASPRIN 150mg RT/OD
6. Tab. CLOPIDOGREL 75mg RT/OD
7. Tab. ATROVAS 40mg RT/OD
8. Inj. MANNITOL 100ml/IV/TID
2/07/21
1. RT FEEDS with 100ml milk 2nd hourly and 100ml water hourly.
2. Inj. PAN 40mg IV/PD
3. Inj. OPTINGURON 1amp in 100ml NS/IV/over 30 minutes
4. Physiotherapy of left upper limb and face
5. Tab. ASPRIN 150mg RT/OD
6. Tab. CLOPIDOGREL 75mg RT/OD
7. Tab. ATROVAS 40mg RT/OD
8. Inj. MANNITOL 100ml/IV/TID
3/07/21
1. RT FEEDS with 100ml milk 2nd hourly and 100ml water hourly.
2. Inj. OPTINGURON 1amp in 100ml NS/IV/over 30 minutes
3. Physiotherapy of left upper limb and face
4. Tab. CLOPIDOGREL 75mg RT/OD
5. Tab. ASPRIN 150mg RT/OD
6. Tab. ATROVAS 40mg RT/OD
7. BP monitoring 4th hourly
Final Diagnosis:
CVA with acute infarct involving MCA territory involving right temporal and parietal lobes.
Advice at discharge:
1. Tab. ASPRIN 150mg RT/OD at 2pm
2. Tab. CLOPIDOGREL 75mg RT/OD at 9pm
3. Tab. ATROVAS 40mg RT/OD at 9pm
4. Tab. ZINCOVIT RT/OD
5. Physiotherapy of left upper limb
Discussion (queries):
1) What is a Transient ischemic attack?
A TIA, also called mini shock occurs when there is temporary loss of blood supply to a part of the brain. It can be caused by blood clots or plaque build up. Symptoms of TIA include muscle weakness and dysarthria as seen in this patient.
2) How do smoking and drinking contribute to CVAs?
Tobacco and alcohol use may have chronic effects on several steps in the gradual atherosclerotic process and more acute effects on the formation of blood clots that often trigger actual clinical events.
More on Cerebrovascular Accidents:
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