75 yr old male
CBBLE UDHC SIMILAR CASE STUDY
CBBLE UDHC SIMILAR CASE STUDY
A 75 year old male was brought to the casualty for further care for known case of CVA diagnosed 1 week back.
HISTORY OF PRESENTING ILLNESS
The patient was apparently asymptomatic 10 days back when he observed deviation of mouth. associated slurring of speech not associated with drooling of saliva.The patient also complained about throat pain and difficulty in swallowing(solids and liquids equally) 10 days back for which Upper GI endoscopy was done(which showed no abnormality). This lead to the patient's reduced appetite. The patient also complained of generalised weakness since 10 days.
This was also associated with headache(diffuse) and approx. 12 episodes of vomitings lasting for 2-3 days 10 days back. The patient also complains of continuous hiccups since 3 days which gets intermittently relieved by itself.
The patient is a k/c/o DM 2 and HTN which was diagnosed 10 years back when the patient went to a local hospital for complaints of headache, giddiness and blurring of vision.
The patient is on Glycoryl, amlodipine and atenolol for the same.
N/k/c/o Thyroid disorders, BA, TB, Epilepsy.
PAST HISTORY
There is H/O snake bite 6 yrs ago following which the attenders stated that the patient did not speak a word for the following 4 days
O/E :
Pt is c/c/c, oriented to t/p/p
Vitals :
Temp: 98.4 f
HR: 82 bpm
RR : 22cpm
BP : 130/90 mm hg
Spo2: 97 @ RA
GRBS : 500 mg/dl
SYSTEMIC EXAMINATION :
CVS : S1 S2 + .
RS : BAE + NVBS +
PA:Soft, non tender
CNS : Tone :normal in all limbs
Power :4/5 in all limbs
INVESTIGATIONS
CXR - Normal
MRI BRAIN
- Acute lacunar infarcts in left lateral aspect of medulla oblongata
- Chronic lacunar infarcts in bilateral lentiform nuclei
- Age related mild cerebral and cerebellar atrophic changes with chronic ischemic changes.
DIAGNOSIS : CVA
TREATMENT :
IVF : NS , RL @ 100ml/hr
INJ. HAI 6U IV/STAT
INJ.PANTOP 40mg IV/BD
INJ. OPTINEURON 1amp in 100ml NS IV/BD
Tab. ECOSPRIN 150mg po/od
Tab. ATORVAS 40mg po/hs
Tab. GLOPITAB 150mg po/odI
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