58yr OLD FEMALE, SSW

23/11/21

58 YR OLD FEMALE , SSW

came with c/o 
Slurring of speech since 3days
Deviation of mouth to left side  since 2days
Weakness of Right UL,LL since 2days.

Patient was apparently asymptomatic 3days ago, then she developed sudden onset of slurring of speech, observes by her daughter, when they checked her BP: 220/100mmhg.
She was taken to a near by hospital, and was given medication TAB . CILIDIN - T.

Patient's daughter observed weakness of Right UL initially, followed by right LL.

K/C/O DM since 10yrs , on TAB. GLIMI -M 

NOT a k/c/o HTN, ASTHMA,TB, EPILEPSY, THYROID.

No similar complaints in the past.
No significant family history.
No known allergic history.

Occupation: House wife
Takes mixed diet
Sleep is decreased
Appetite is normal
Bowel and bladder movements are normal.
No any addictions

O/E
pt is C/C/C
NO pallor, icterus, cyanosis,clubbing, lymphadenopathy, edema.
No malnutrition
No dehydration.

VITALS:
TEMP: 98.5F
BP: 110/80mmhg
PR: 84BPM
RR: 18CPM
GRBS: 251mg/dl
SPO2: 99% RA

SYSTEMIC EXAMINATION:
CVS: S1S2+
RS: BAE +, NVBS +
P/A: soft, non tender

CNS: 
Pt is conscious.
Speech- slurred
No signs of meningeal irritation.

 Tone                RT.          LT
UL     decreased     normal
LL.    2/5.                normal

Power
UL.         decreased.      4/5
LL.         2/5.                  4/5

Reflexes 
              B.       T.         S.       A.       K.        P

Right.   -.          -.          -.        -.       -.         E
Left.     2+.       2+.      2+.     2+.    -.         E


 DIAGNOSIS:

CVA WITH RIGHT SIDED HEMIPARESIS
With RIGHT UMN FACIAL PALSY ( ?BROCAS APHASIA)
LEFT SIDE ,ACUTE INFARCT in LEFT MCA TERRITORY
(CENTRUM SEMI OVALE REGION )
WITH TYPE 2 DM 

Treatment given:
1. Inj. Optineuron 1amp in 1NS/I.V/OD
2 Tab. Ecosprin 75mg /PO/OD
3.Tab. Atorvas 40mg /PO/OD
4. Tab. Clopidogrel 75mg /PO/OD
5. Inj. HAI  S/C  PRE MEAL 
        8AM - 2PM - 8PM 
6. BP charting 4th hrly
7. PHYSIOTHERAPY for RT UL,LL
8.GRBS 7 0 PROFILE
    8AM - 2PM - 8PM - 2AM - 10AM - 4PM - 10PM 

24/11/21,SSW
SOAP NOTES DAY 2

S: 
not able to take solid food
Dragging type of pain in right lower limb
No sleep in the night

O:
Pt is c/c/c
TEMP: 97.6F
BP: 110/70mmhg
PR: 80BPM
RR: 18CPM
GRBS: 209mg/dl

SYSTEMIC EXAMINATION:
CVS: S1S2+
RS: BAE +, NVBS +
P/A: soft, non tender

CNS: 
Pt is conscious.
Speech- slurred
No signs of meningeal irritation.

Tone     RT.              LT
UL  decreased     normal
LL.     2/5.            normal

Power
UL.   decreased.       4/5
LL.        2/5.               4/5

Reflexes 
              B.  T.  S.  A.  K.  P

Right.      -.  -.  -.   -.    -.     E
Left.       2+. 2+. 2+. 2+. -. E

A:

CVA WITH RIGHT SIDED HEMIPARESISHEMIPARESIS 
With RIGHT UMN FACIAL PALSY ( ?BROCAS APHASIA)
LEFT SIDE ,ACUTE INFARCT in LEFT MCA TERRITORY
(CENTRUM SEMI OVALE REGION )
WITH TYPE 2 DM 

P:
1. Tab. MVT po/od
2 Tab. Ecosprin 75mg /PO/OD
3.Tab. Atorvas 40mg /PO/OD
4. Tab. Clopidogrel 75mg /PO/OD
5. Inj. HAI S/C PRE MEAL 
        8AM - 2PM - 8PM 
6. BP charting 4th hrly
7. PHYSIOTHERAPY for RT UL,LL
8.GRBS 7 0 PROFILE
    8AM - 2PM - 8PM - 2AM - 10AM - 4PM - 10PM 

25/11/21 
SOAP NOTES DAY 3
SSW

S:
pain in right upper and lower limbs
Not able to swallow solid food

O:

Pt is c/c/c
TEMP: 97.2F
BP: 100/70mmhg
PR: 64BPM
RR: 18CPM
GRBS: 175mg/dl

SYSTEMIC EXAMINATION:
CVS: S1S2+
RS: BAE +, NVBS +
P/A: soft, non tender

CNS: 
Pt is conscious.
Speech- slurred
No signs of meningeal irritation.

Tone        RT.       LT
UL decreased normal
LL.  2/5.            normal

Power
UL.       decreased.   4/5
LL.       2/5.               4/5

Reflexes 
              B. T. S. A. K. P

Right.     -.  -.  -.  -.  -.  E
Left.      2+. 2+. 2+. 2+. -. E

A:

CVA WITH RIGHT SIDED HEMIPARESISHEMIPARESIS 
With RIGHT UMN FACIAL PALSY ( ?BROCAS APHASIA)
LEFT SIDE ,ACUTE INFARCT in LEFT MCA TERRITORY
(CENTRUM SEMI OVALE REGION )
WITH TYPE 2 DM 

P:
1. Tab. MVT po/od
2 Tab. Ecosprin 75mg /PO/OD
3.Tab. Atorvas 40mg /PO/OD
4. Tab. Clopidogrel 75mg /PO/OD
5. Inj. HAI S/C PRE MEAL 
        8AM - 2PM - 8PM 
6. BP charting 4th hrly
7. PHYSIOTHERAPY for RT UL,LL
8.GRBS 7 0 PROFILE
    8AM - 2PM - 8PM - 2AM - 10AM - 4PM - 10PM 

Physiotherapy done yesterday.






























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