amc 7/11/21

AMC BED 7
 
YESTERDAY'S ADMISSION

60yr old , daily wage labourer by occupation earning around Rs.400-500/day, presented to casualty with inability to move his right upper and lower limb with deviation of mouth to left side , with slurring of speech.
His daily routine includes, waking up, attending nature's call, having a cup of tea, rice for breakfast,going to work , coming for lunch , returning back home indulging himself in alcohol, around 90ml whiskey daily since 20-30 yrs and smoker around a pack of beedies  daily , (18 beedies /1pack).

HOPI:

He was apparently asymptomatic till yesterday afternoon 3-4 pm , he experienced sudden onset of deviation of mouth to left side with slurring of speech while having food and was encouraged to drink ( as it was the solution)., with no apparent weakness.

Today mrng following his daily routine around 7:30am , after having cup of tea, he suddenly fell from chair and was unable to lift his right upper and lower limbs.

PAST HISTORY:

No significant past history
No significant family history
No significant drug history.

Not a k/c/o diabetes mellitus, hypertension, asthma, TB, epilepsy .

PERSONAL HISTORY:
Takes mixed diet
Daily wage labourer
Normal appetite
Regular bowel and bladder movements
No known allergies.
ADDICTIONS:
alcohol- daily 90ml whiskey since 20-30 yrs.
Smokes 1pack of beedies since 20-30 years.

O/E:

Pt is C/C/C.
No pallor,icterus,cyanosis, clubbing,lymphadenopathy edema
No malnutrition.
Mild dehydration.
VITALS:
BP: 140/90MMHG
PR:74BPM
RR:18CPM
TEMP: 98.7F
SPO2:94% @ROOM AIR
GRBS: 145MG/DL
I/O: 1100/1500ML

CVS: S1S2+,NO MURMERS
RS: NVBS+ , decreased breath sounds in left ISA.
PER ABDOMEN:OBESE
   soft, non tender.
CNS: 
consciousness+
Speech: slurred.
No any signs of meningeal irritation.
Deviation of mouth to left side.
Power:.  R.        L
     UL.    0/5.     5/5
     LL.     0/5.     5/5
TONE.    R.                   L
    UL.    Decreased.   Normal
    LL.    Decreased.   Normal
REFLEXES:.     R.         L
  BICEPS.      2+.        2+
  TRICEPS.    1+.       2+
  SUPINATOR 1+.      1+
  KNEE.          3+.        2+
  ANKLE.        -.            -
CEREBRAL SIGNS:
NO FINGER NOSE COORDINATION.

NO KNEE HEEL IN COORDINATION.

INVESTIGATIONS:
HB: 15.6GM/DL
RBC: 4.8
PCV: 42.7
WBC:7,300
PLC: 1.84 LAKH/CUMM

ESR: 29MM
BT: 1min 50sec.
CT: 4min 25sec
PT: 17.7 sec
APTT: 42sec
INR: 1.5

RBS: 89mg/dl

Na : 139
K.  : 3.3
Cl.  : 95

Serology: HIV, HBSAG, HCV NEGATIVE.

PROVISIONAL DIAGNOSIS:

RIGHT SIDED HEMIPLEGIA SECONDARY TO ACUTE ISCHEMIC STROKE.

? LEFT MCA TERRITORY

PLAN 0F CARE:
1. IVF NS,RL @50ml/hr
2.inj.pantop 40mg /iv/OD
3.inj. OPTINEURON 1amp in 100ml ns /iv/od
4. T.Ecospirin 75mg /po/od
5. T. Clopidogrel 75mg /po/od
6. T. Atorvas 40mg /po/OD
7.RT feeds 100ml free water
          100ml protein powder 2nd hrly.
8. Physiotherapy of right UL,LL
9.BP,PR,SPO2 charting 2nd hrly.

SHIFTED TO WARD

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