65yr old Male with CVA secondary to Acute Ischemic Stroke
65 year old male with CVA secondary to Acute Ischemic Stroke
19/12/22
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K.Medha Reddy, intern
Roll No: 61
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.
CASE:
A 65 year old male residing at miryalguda was brought to casualty in an alternate state of mRS of 4 with history of involuntary tonic clonic movements of both upper limbs and lower limbs around 9:10am in the morning.
C/O of weakness of Left Upperlimb and Lower limb since 1 week.
Difficulty in speaking and swallowing since 1week
H/O Involuntary movements involving all 4 limbs in the morning today.
HOPI:
He was apparently assymptomatic 5-6 years back then he had C/O deviation of mouth to one side, not responding to commands, only 1 episode
lasting for 2-3 mins, MRI was done they were informed to be clots in the brain ( reports not available) and was also started on anti epileptics and anti platelets he was also detected to be diabetic and was started on OHA’s, he used anti epileptics for 2-3 years and stopped on his own saying he was better for 2 months.
Later on he had deviation of mouth to left side and wasn’t able to speak they took him to a nearby hospital and was also said to be in altered state CT was done and were informed there was some minor ?bleed and was started on ? Coagulants saying because of blood thinners he developed bleed and was also diagnosed to be hypertensive and was started on telma AM (5/50mg BD )
6 months back he developed weakness of both left upper limb and lower limb associated with slurring of speech and stayed back in hospital for one week and was in an altered state and was fed through ryles and foleys was placed ( as recalled by the attendant ) and his seizures medication was also changed ??
He regained his functions, was able to walk with the help of support and was able to talk normally without any slurring within a month
Since one week patient is irritable showing altered behaviour, agitated and wasn’t able to move his left upper limb and lower limb as his prior self, and showing a delayed response, when was talked by his son
Today morning around 9:10am developed involuntary movements GTCS type, episode lasting for 5-10 mins and post ictal state of 20-30 mins
Significant alcohol history +
General Examination:
Patient conscious
Irritable
Not oriented to time, place, person
Positive findings :
Motor left UL, LL 2/5
Right UL and LL able to move against resistance ( able to fight back on holding )
Tone - increased on left side
Reflexes exaggerated left side with plantars withdrawal
Supinator reflex:
https://youtube.com/shorts/dcHI7BLhuXU?feature=share
ICU bed 5 : 20/12/22
GM 1
Day 1
Dr. Raveen
Dr. Shashikala
Dr. Venkat Sai
Dr. Prachethan
Dr. Vivek
Pt came with H/O Involuntary movements involving both upper and lower limbs
No H/O tongue biting, frothing
Post ictal confusion +
S: pt is conscious
No new complaints
O:
On examination pt is conscious
BP: 150/90 mmHg
PR: 90 bpm
CVS: S1, S2 heard, no murmurs
RS: BAE +, NVBS
P/A: soft
CNS:
Tone. UL. LL
Right N N
Left. ⬇️ ⬇️
Reflexes: R. L
Biceps: +1. 3+
Triceps:. +1. 3+
Supinator:. +1. 2+
Knee: +1. 2+
Ankle: +1. 2+
Plantar Ext. Ext
A: Old CVA secondary to Acute Ischemic Stroke, acute episode
P:
inj. Levipil 500mg IV BD
Inj. EcosprinAV 75/10 PO OD HS
Inj. Optineuron 1amp in 100 ml NS IV OD
Physiotherapy of left upper and lower limb
ICU bed 5: 21/12/22
GM 1
Day 2
Dr. Raveen
Dr. Shashikala
Dr. Venkat Sai
Dr. Prachethan
Dr. Vivek
Pt came with H/O Involuntary movements involving both upper and lower limbs
No H/O tongue biting, frothing
Post ictal confusion +
K/c/o DM, HTN
S: pt is conscious
No new complaints
O:
On examination pt is conscious
Temp: 99.5 F
SPO2 : 98 on RA
BP: 150/80 mmHg
PR: 83 bpm
CVS: S1, S2 heard, no murmurs
RS: BAE +, NVBS
P/A: soft
CNS:
Speech +
Orientation -
Pupils: B/L NSRL
Cranial nerves: Right side deviation of mouth
Motor:
Power: R. L
UL. 5/5. 2/5
LL. 5/5. 2/5
Tone. R L
UL N decreased
LL N decreased
Reflexes: R. L
Biceps: +2. 3+
Triceps:. +1. 2+
Supinator:. +1. 2+
Knee: - -
Ankle: - -
Plantar flexion. Ext
Cerebellar signs : not able to elicit
Sensory system: couldn't be evaluated
A: Altered sensorium secondary to Acute Ischemic Stroke?post ictal confusion
Lt hemiparesis secondary to Acute Ischemic Stroke? Rt MCA territory
GTCS secondary to Old CVA H/O recurrent CVA
K/c/o DM, HTN
P:
inj. Levipil 500mg IV BD
Inj. EcosprinAV 75/10 PO OD HS
Inj. Optineuron 1amp in 100 ml NS IV OD
Inj. HAI SC TID Premeal
Tab. Telma-AM 40mg PO OD
Physiotherapy of left upper and lower limb
ICU bed 5 : 22/12/22 at 8 AM
GM 1
Day 3
Dr. Raveen
Dr. Shashikala
Dr. Venkat Sai
Dr. Prachethan
Dr. Vivek
Pt came with H/O Involuntary movements involving both upper and lower limbs
No H/O tongue biting, frothing
Post ictal confusion +
K/c/o DM, HTN
S: pt is conscious
No new complaints
O:
On examination pt is conscious
Temp: 97.5 F
SPO2 : 98 on RA
BP: 130/80 mmHg
PR: 82 bpm
CVS: S1, S2 heard, no murmurs
RS: BAE +, NVBS
P/A: soft
CNS:
Speech - blurred
Oriented to person
EOM +
Pupils: B/L NSRL
Cranial nerves: Right side deviation of mouth
Motor:
Power: R. L
UL. 5/5. 2/5
LL. 5/5. 2/5
Tone. R L
UL N decreased
LL N decreased
Reflexes: R. L
Biceps: +2. 3+
Triceps:. +2. 2+
Supinator:. +1. 2+
Knee: - -
Ankle: - -
Plantar flexion. Ext
Cerebellar signs : not able to elicit
Sensory system: couldn't be evaluated
A: Altered sensorium secondary to Acute Ischemic Stroke?post ictal confusion
Lt hemiparesis secondary to Acute Ischemic Stroke? Rt MCA territory
GTCS secondary to Old CVA H/O recurrent CVA
K/c/o DM, HTN
P:
inj. Levipil 500mg IV BD
Inj. EcosprinAV 75/10 PO OD HS
Inj. Optineuron 1amp in 100 ml NS IV OD
Inj. HAI SC TID Premeal
Tab. Telma-AM 40mg PO OD
Physiotherapy of left upper and lower limb
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