60 year old female with CVA

This is a case of 60 year old female (fruit and vegetable vendor) which chief complaints of giddiness,  right upper limb and lower limb weakness and slurring of speech. 

CHEIF COMPLAINTS:  

• Giddiness and generalised weakness around 6pm in the evening 
• Right upper limb & lower limb weakness and slurring of speech around 8pm in the night 

HISTORY OF PRESENT ILLNESS: 

• Patient was apparently a symptomatic till 6pm in the evening. She suddenly started developing giddiness, after which the patient was taken to the local RMP and found BP was 160/80 mmHg 
• She was prescribed T.amlong 5mg and BP was lowered to (systolic 130mmHg) 
• Giddiness was non rotational, no postural variation, no change with position of the head, not associated with blurring of vision or headaches. Lasted for 30 min. 
• The taken to the local hospital where sublingual NTG was given.
• followed by sudden onset of weakness of right upper & lower limbs and slurring of speech. Not able to lift/move the limbs from the bed. 
• No loss of touch, pain, temperature sensations on the right. Not associated with difficulty in swallowing, deviation of mouth, tip of tongue. 

HISTORY OF PAST ILLNESS: 

Not a k/c/o of diabetes mellitus, hypertension. 

TREATMENT HISTORY: 

Nothing significant 

PERSONAL HISTORY: 

• Appetite : normal 
• Non vegetarian 
• Bowels: regular 
• Micturition: normal 

FAMILY HISTORY: 

Nothing significant 

PHYSICAL EXAMINATION: 

GENERAL : 

• Pallor - mild 
• Oedema - B/L pedal oedema
• No signs of icterus, cyanosis, clubbing of fingers/toes, lymphadenopathy
• Mild dehydration 

VITALS: 

• Temperature - afebrile 
• Pulse- regularly irregular 
• BP - 130/90 mmHg 
• SpO2: 96% at room air 
• GRBS- 160 mg%

SYSTEMIC EXAMINATION: 

CVS: 

S1, S2 heard 

RESPIRATORY SYSTEM: 

BAE + 

PER-ABDOMEN: 

• Shape: scaphoid 
• Tenderness: absent 
• Bowel sounds: yes 
• No palpable mass, no organomegaly

CENTRAL NERVOUS SYSTEM 

•  Level of consciousness : drowsy 1 arousable
• Speech : slurred 
• Signs of meningeal irritation: none 
• Motor system: right - tone absent 
•                                    Power - UL,  LL
•                                                 1/5 , 0/5 
• Sensory system : + 
• Glasgow scale: E4V5M6 

PROVISIONAL DIAGNOSIS: 

Acute ischemic CVA with right hemiplegia 2° to ? Cardioembolic with slurring of speech 

INVESTIGATIONS: 

1. SERUM MAGNESIUM 

2. HEMOGRAM

3. LIVER FUNCTION TESTS

4. HBsAG: 

 

5. Anti HCV antibodies: 

6. ECG:

7. Lipid profile 

8. RFT 

9. HIV 1/2 rapid test: 

TREATMENT: 

24/7/21:

Tab.Atorvas - 20 mg - HS

Tab.Ecospirin-75mg- OD

Tab.Clopidogrel -75mg-OD

25/7/21:

Tab.Ecospirin-75mg-OD 

Tab.Clopidogrel-75mg-OD

Tab.Atorvas-20mg-HS

26/7/21:

Tab.Ecospirin-75mg-OD

Tab.Clopitab-75mg-OD

Tab.Atorvas-20mg-OD 

27/7/21:

Tab.Ecospirin-75mg-OD

Tab.Clopitab-75mg-OD

Tab.Atorvas-20mg-OD