75 yr old male with Rt hemiparesis

  

A 75 year old male patient came to the casuality on 18/10/21 at 8 pm with

c/o sudden of weakness of Rt UL and LL 

c/o deviation of mouth to the left

c/o slurring of speech 

HOPI:

A 75 yr old male patient, was apparently asymptomatic 10 years back when he developed sudden onset shortness of breath and chest pain, diagnosed as ? MI, underwent PTCA with ? 2 DES to RCA and was on Tab. Atorvar 20 mg OD till now.

Patient was a chronic cigar smoker for 40 years but stopped smoking after PTCA.

Patient had c/o cough - with expectoration (yellowish in colour, non- foul smelling, non-blood tinged) since 10 days, not a/w fever.

At 7.00 pm today, while patient drinking tea, he had sudden onset of right UL and LL, with deviation of mouth to the left and slurring of speech. He phoned up his attenders and upon their arrival to the hospital his Rt UL weakness was resolving and deviation of mouth resolved.

 

PAST HISTORY:

The patient is a k/c/o Diabetes and Hypertension since 11 years.

On medication:

Tab. Atorvas PO/ OD

Tab. Glycomet PG-2 PO/OD

( Glimi 2 mg+ metformin 500 g) 

Tab. met XL 25 mg PO/OD

Tab. Enalapril 5 mg PO/OD

VITALS ON ADMISSION:

Temperature-afebrile 

BP- 150/100 mmhg

PR- 77 bpm

RR- 17 bpm

Spo2- 97 %

RBS- 157 mg/dl

O/E:

CVS- S1 S2 +. No murmurs

RS- NVBS+. No crepts

P/A- Scaphoid, soft, Non tender 

CNS- 

pt is conscious 

Speech- slurred

No meningeal signs 

No cerebellar signs

Motor system   

                 Rt            Lt

Tone

       UL   Increased   N

       LL.   Increased  N

      

Power

       UL.      4/5.      4/5 

       LL.       4/5.     4/5

Sensory system- normal 

Cranial nerves- normal 

GCS- 15/15 

Investigations:

ECG

X-RAY 

MRI BRAIN 

Impression:

Old infarct in left lentiform nucleus 

Diffuse cerebral atrophy 

2D ECHO

Impression:

EF- 50%

Fair LV systolic function 

Diastolic dysfunction +

RWMA +

Trivial TR/AR+

DIAGNOSIS:

Small vessel ischaemic changes with hypertensive microbleeds in basal ganglia.

K/c/o HTN and DM 

H/O CAD with 2 PTCA 11 years back 

TREATMENT IN THE HOSPITAL:

Day 1:

Tab. Atorvas 40 mg PO/ H/S

Tab. Ecosprin 75 mg /PO/OD

Tab. Clopidogrel 75 mg / OD - 2 pm

GRBS 6th hourly pre- meal 

Tab. Glimiperide 2 mg + Metformin 500 mg OD

DAY 2:

Tab. Atorvas 40 mg PO/ H/S

Tab. Ecosprin 75 mg /PO/OD

Tab. Clopidogrel 75 mg / OD - 2 pm

GRBS 6th hourly pre- meal 

Tab. Glimiperide 2 mg + Metformin 500 mg OD

Patient lama on 20/10/21