CVA case
General Medicine E-log
Final diagnosis: CVA with history of HTN and DM since the last 13 years.
A 75 year old, male patient presented to the OPD with complaints of headache and dizziness.
Date of admission: 25/02/22
Chief complaints:
The patient came to the OPD with complaints of severe headache and dizziness. He also complained of hiccups since the last 3 days.
History of present illness:
The patient was apparently asymptomatic 10 days ago when he got a headache and suffered 3 episodes of vomitting. He developed throat pain and difficulty in swallowing later on the same day. He was taken to a hospital in Nalgonda where upon examination, he was diagnosed to have suffered from a CVA for which he recieved treatment.
He was apparently discharged after four days. However he was soon brought to the hospital when he complained of a headache and dizziness. When examined, he had uncontrolled sugar levels (GRBS - 588 mg/dl). He was admitted in the hospital on 25/02/22 and was shifted to the ward from the ICU 2 days ago.
History of past illnesses:
The patient is a known case of HTN and DM since the past 13 years.
He had recently suffered from a CVA - acute lacunar infarcts in left lateral aspect of medulla oblongata.
He is not a known case of epilepsy, thyroid disorders or asthma.
Personal history:
Occupation: stopped working about 15 years ago.
Diet: mixed
Appetite: decreased
Sleep:
Bowel and bladder habits:
Drug history:
Recieved treatment for CVA 10 days ago, it included diet change, I.V. fluids and I.V. antibiotics.
Family history:
No significant family history.
General examination:
Patient is conscious, coherent and co-operative.
No pallor, icterus, cyanosis, clubbing, koilonychia, generalized lyphadenopathy or edema was seen.
Vitals:
BP: 100/60 mmHg
PR: 115 bpm
RR: 20 cpm
Temperature: afebrile
GRBS: 588 mg/dl
Systemic examination:
CNS:
Speech: slurred
No finger-nose coordination.
No knee-heel coordination.
Tone: R L
UL - normal normal
LL - normal normal
Power: R L
UL - 4/5 4/5
LL - 4/5 4/5
CVS:
S1 and S2 were heard.
No murmurs
No thrills
Respiratory system:
BAE: present
NVBS heard
Per Abdomen:
Soft, non tender
Investigations:
On 18/02/22
X-ray: PA view of chest
Impression: normal study
Upper GI Endoscopy
ECG
ECG
25/02/22
Treatment given (present course in the hospital):
25/02/22
1. IVF normal saline and ringer lactate at 100ml/hour.
2. Inj. HAI 6IU IV
3. Inj. PAN 40mg/IV/OD
4. Inj. OPTINEURON 1 amp in 100ml NS/IV/OD
5. Tab. ECOSPRIN 150mg PO/OD
6. Tab. ATORVAS 40mg PO/HS
7. Tab. CLOPITAB 150mg PO/OD
26/02/22
1. IVF normal saline and ringer lactate at 100ml/hour.
2. Inj. HAI 6IU IV
3. Inj. PAN 40mg/IV/OD
4. Inj. OPTINEURON 1 amp in 100ml NS/IV/OD
5. Tab. ECOSPRIN 150mg PO/OD
6. Tab. ATORVAS 40mg PO/HS
7. Tab. CLOPITAB 150mg PO/OD
27/02/22
1. IVF normal saline and ringer lactate at 100ml/hour.
2. Inj. HAI 6IU IV
3. Inj. PAN 40mg/IV/OD
4. Inj. OPTINEURON 1 amp in 100ml NS/IV/OD
5. Tab. ECOSPRIN 150mg PO/OD
6. Tab. ATORVAS 40mg PO/HS
7. Tab. CLOPITAB 150mg PO/OD
28/02/22
1. IVF normal saline and ringer lactate at 100ml/hour.
2. Inj. HAI 6IU IV
3. Inj. PAN 40mg/IV/OD
4. Inj. OPTINEURON 1 amp in 100ml NS/IV/OD
5. Tab. ECOSPRIN 150mg PO/OD
6. Tab. ATORVAS 40mg PO/HS
7. Tab. CLOPITAB 150mg PO/OD
Comments
Post a Comment