ACUTE ISCHEMIC STROKE

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A 65 years old male patient came to OPD with the chief complaints of 

Weakness of left upper limb , left lower limb, slurring of speech since 2 days

Tingling sensations in right upper limb since 20 days

HISTORY OF PRESENT ILLNESS :

Patient was apparently asymptomatic 20 days back then he developed tingling sensation in right upper limb which gradually progressed and developed generalized weakness for which he was taken to hospital and was diagnosed with acute infarcts and chronic infarcts and was treated conservatively and

then 2 days back he developed slurring of speech and weakness of left upper and lower limbs.

HISTORY OF PAST ILLNESS :

History of right hemiparesis 6yrs back

History of hypertension since 6yrs

History of DM since 5yrs

No H/o Asthma , epilepsy, TB . 

TREATMENT HISTORY :

Patient is under medication for HTN and DM

HTN : Telmisartan 40mg

            Amlodipine 5mg

DM : metformin 250mg

PERSONAL HISTORY :

Married 

Mixed diet 

appetite normal

Regular bowel habit 

Micturation normal 

Sleep adequate

Addictions: 

Alcohol regular stopped since 5years

FAMILY HISTORY :

NO H/O :-HTN,DM ,EPILEPSY ,TB

No significant family history 

GENERAL EXAMINATION :

NO pallor 

 No .icterus 

 No .cynosis 

 No .lymphadenopathy 

 No.clubbing 

PHYSICAL EXAMINATION-:

Temperature-:afibrile 

Pulse rate -: 96/min

Resp rate -:17/min

Bp -:150/90mmHg

 SYSTEMIC EXAMINATION :

CVS-; 

        S1,S2 HEARD 

        NO MURMERS 

RESPIRATORY SYSTEM-:

         No dyspnea 

          No wheeze 

          Position of trachea -;central 

         Normal vesicular breath sounds

ABDOMEN-:

          Shape scaphoid 

          No tenderness 

          No palpable mass 

           No palpable spleen and liver 

          No dilated veins

          No scars

CNS-:

         Consious, coherent ,cooperative 

         Speech  slurred

         No neck stiffness

Cranial nerves : normal

SENSORY SYSTEM :

        Able to percieve-:pain , temp

Motor system : 

Tone :                Rt.     Lt

                UL     N.       Increased 

                LL.     N.       Increased

Power :.               Rt.     Lt

                UL.       4/5.   3/5

                LL.        4/5.   0/5

 PROVISIONAL DIAGNOSIS :

Acute ischemic stroke

Left hemiparesis 

 

INVESTIGATIONS:

Complete blood picture

Complete urine examination

Liver function tests

Renal function tests 

ECG

MRI brain

TREATMENT :

Tab. ECOSPRIN 150mg (po/0D).

X  ---  2pm — X

Tab. CLOPITAB 75mg (Po/0D)

X  --  2pm --  X

Tab. ATORVAS 40mg (PO/OD)

X  --  X  --  8pm.

RT  FEEDS. 

MONITOR VITALS