66M with Rt hemiparesis ?HfrEF
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66 years old male patient came to OPD with C/O Right sided weakness of Both UL and LL since 3 days
Patient was apparently normal 3 days back then at morning after his work while eating breakfast he couldn't mix food, immediately they went to local RMP and took some injections and went back home in hope of recovery, next day morning he developed Right lower limb weakness
No deviation of tongue
No deviation of angle of mouth
No drooping of eyelid
Past History -
Not a k/c/o HTN,DM,TB,CAD, CVD,Asthma
Personal history -
He is married and a farmer by occupation
He has a habit of drinking alcohol (180ml) daily from the past 40 years and smokes beedis(one pack-18) daily from the past 40 years
Diet - mixed
Appetite - Normal
Bowel & bladder movements - regular
Family history - not significant
On Examination
patient is c/c/c
No pallor , icterus , cyanosis, clubbing lymphadenopathy , edema
Vitals -
Temp - Afebrile
PR - 83bpm
BP - 110/80 mmHg
RR -20 cpm
SpO2- 98%@RA
Systemic examination -
CVS - S1 S2 heard,no murmurs
RS -BAE present
CNS:
HMF - intact
Power RT LT
UL 2/5 4/5
LL 3/5 4/5
Tone RT LT
UL Decreased Normal
LL Decreased Normal
Reflexes RT LT
Biceps - -
Triceps - -
Supinator - -
Knee - -
Ankle - -
Cerebellar-
finger-nose in coordination-NO
Knee-Heel in coordination-NO
P/A - soft , non tender.
Provisional diagnosis -
CVA WITH HEART FAILURE WITH REDUCED EJECTION FRACTION
Investigations:
Day 3 soap notes
S-C/O Right sided weakness of both UL&LL
O-
O/E:Pt-C/C/C
Temp:Afebrile
PR:78bpm
BP:120/80 mm of hg
RR:20cpm
CVS:S1,S2 heard,no murmurs
RS:BAE+,NVBS heard
P/A:Soft,non tender
A-CVA with heart failure with reduced ejection fraction
P-
T.Ecospirin 150mg PO/OD
T.Clopidogrel 150mg PO/OD
T.Atorvastatin 40mg PO/OD
T.lasix 20mg PO/OD
Inj.Optineuron IV in 100ml NS/IV stat
GRBS monitoring 4th hourly
Physiotherapy of Right Upper limb and lower limb
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