202320552

 

Case History and Clinical Findings

PATIENT CAME WITH C/O INABILITY TO SPEAK SINCE 8 HOURS, DEVIATION OF ANGLE OF MOUTH SINCE 8 HOURS, DROOLING OF SALIVA SINCE 8 HOURS

PATIENT WAS APPARENTLY ASYMPTOMATIC 4 DAYS AGO, HE THEN HAD RTA BY FALL FROM BIKE AND SUSTAINED RIGHT ACETABULAR FRACTURE AND WAS ON CONSERVATIVE MANAGEMENT FROM THEN BY TRACTION AND WEIGHT BEARING. TODAY MORNING AT 8AM PATIENT HAD SUDDEN ONSET SLURRING OF SPEECH 8 HOURS AGO WITH DEVIATIN OF ANGLE OF MOUTH TO RIGHT AND DROOLING OF SALIVA AND FOOD CONTENT FROM THE MOUTH.

N/H/O INVOLUNTARY MOVEMENTS, LOSS OF CONCIUSNESS, HEADACHE, GIDDINESS, VOMITING.

N/H/O NECK RIGIDITY, WEAKNESS OF UL OR LL PAST HISTORY

K/C/O HTN SINCE 5 YEARS , DM SINCE 2 YEARS CVA 5 YRS AGO

 

GENERAL EXAMINATION

 

GENERAL EXAMINATION :

PATIENT IS

MODERATELY BUILT AND NOURISHED .

NO SIGNS OF ICTERUS , CYANOSIS , CLUBBING ,LYMPHADENOPATHY, EDEMA.

 

 

VITALS : TEMPERATURE:98.6 F PR - 86 BPM

BP - 130/90 MMHG RR - 23 CPM

SPO2 - 98% ON RA GRBS - 190 MG/DL

 

CVS- S1S2+ NO MURMURS R/S- BAE+ NVBS

P/A- SOFT, NT CNS-

GCS- E4V1M6 POWER RT LT UL 5/5 5/5

LL 4/5 5/5 TONE RT LT UL N N

LL N N REFLEXES RT LT BICEPS 3+ 1+

TRICEPS 2+ 1+

SUPINATOR 2+ 1+

KNEE 3+ 1+

ANKLE 1+ 1+ PLANTAR FLXN ETXN

SENSATIONS OVER FACE PRESENT DEVIATION OF ANGLE OF MOUTH TO RIGHT DECREASED FROWNING ON LEFT SIDE

 

UNABLE TO PROTRUDE TONGUE APHASIA

 

COURSE IN HOSPITAL

PATIENT PRESENTED WITH THE ABOVE MENTIONED COMPLAINTS AND WAS EVALUATED CLINICALLY AND WITH THE APPROPRIATE INVESTIGATIONS . PATIENT WAS DIAGNOSED TO HAVE RECURRENT CVA WITH ACUTE INFARCT IN RIGHT INSULAR REGION. RYLES TUBE FEEDINGS WERE GIVEN AND WAS STARTED ON DUAL ANTIPLATELETS. ORTHO OPINION WAS TAKEN I/V/O RIGHT ACETABULAR FRACTURE AND ADVISED CONSERVATIVE MANAGEMENT WITH SKIN TRACTION AND WEIGHT BEARING.

NEUROLOGIST OPINION WAS TAKEN AND WAS DIAGNOSED AS ? OPERCULAR SYNDROME. POOR PROGNOIS REGARDING THE IMPROVEMENT IN PATIENT CONDITION HAS BEEN EXPLAINED. PATIENT WAS HEMODYNAMICALLY STABLE AT THE TIME OF DISCHARGE. RYLES TUBE CARE HAS BEEN EXPLAINED AND RISK OF ASPIRATION EXPLIAINED TO PATIENT ATTENDERS.

 

Investigation

HB- 13.5 MG/DL

PCV- 40.4

TLC- 13,600

RBC- 4.95

FBS- 162

HBA1C- 7.4

 

 

2D ECHO ON 10/5/23 CONCENTRIC LVH, NO RWMA NO AS/MS. SCLEROTIC AV NO MR/AR. TRIVIAL TR

GOOD LV SYSTOLIC FUNCTION. DIASTOLIC DYSFUNCTION + NO PAH

 

 

Treatment Given(Enter only Generic Name)

IVF NS@ 75ML/HR

RT FEEDS- 200ML MILK 4TH HRLY 200 ML WATER 2ND HRLY

 

TAB. ASPRIN+ CLOPIDOGREL 75/75MG RT/OD TAB. ATORVASTATIN 20MG PO/HS

TAB ULTRACET 1/2 TAB PO/QID GRBS 7 POINT PROFILE

INJ. HAI SC TID AS PER GRBS NEB. WITH DUOLIN 6TH HRLY NEB. WITH BUDECORT 8TH HRLY TAB. CLINIDIPINE 10MG PO/BD

MONITOR VITALS AND INFORM SOS

Advice at Discharge

RT FEEDS- 200ML MILK 4TH HRLY 200 ML WATER 2ND HRLY

TAB. ASPRIN+ CLOPIDOGREL 75/75MG RT/OD TAB. ATORVASTATIN 20MG PO/HS

TAB ULTRACET 1/2 TAB PO/QID X 3 DAYS INJ. HAI SC TID 6U-6U-6U

NEB. WITH DUOLIN 6TH HRLY NEB. WITH BUDECORT 8TH HRLY TAB. CLINIDIPINE 10MG PO/BD


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