Manish Kumar 129
41year old male patient came to causality with c/o of tingling sensation of the right UL and right LL since 2days
CNS-
2D Echo
USG abd
Chest X ray
Provisional diagnosis:-
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41year old male patient came to casuality with chief compliant of tingling sensation of the right upper limb and right lower limb since 2days
,c/o weakness of the right upper limb and right lower limb since 2days.
History of present illness:-
Patient was apparently asymptomatic 2days back then he developed tingling sensation of the right upper limb and right lower limb since 2days & history of decrease in strength, weakness of the right upper limb and right lower limb,No History of headache, vomitings etc.No history of sudden blurring of vision etc.
Past History:-k/c/o Hypertension since 3days & started on Tab.CINOD 10mg PO/OD
O/E
Pt was c/c/c
No pallor icterus clubbling lymphadenopathy edema
Temp:-afebrile
PR-98bpm
RR-22cpm
Bp-170/90mmhg
Spo2-98%
Grbs-141mg
CVS-s1s2 heard,no murmurs
Rs- BAE+,NVBS+
/PA- soft, non tender
consciousness
Rt Lt
Tone UL reduced normal
LL reduced normal
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes
B ++ ++
T ++ ++
S ++ ++
K ++ ++
A ++ ++
P W E
Investigation
MRI Brain
CVA WITH ACUTE ISCHEMIC STROKE WITH INFARCT IN THE LEFT THALAMUS WITH DENOVO DETECTED HTN
Treatment:-
1)TAB.ASPIRIN 150MG PO/OD
2)TAB.CLOPIDOGREL 75MG PO/OD
3)TAB.ATORVAS40MG PO/OD/H/S
4)TAB.PAN 40MG PO/OD
5) MONITOR BP 4TH HRLY
6)TAB.PREGABALIN 75MG /H/S
7)TAB.AMLONG 5MG PO/OD
8) INFORM SOS
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