55Y/M with Giddiness and lethargy

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55 year old male painter by occupation came to casualty with cheif complaints of 

1.Giddiness since 2 days

2.lethargy since 1 day

Patient was apparently alright 2 days back then at 9:00 am he had sudden episode of giddiness while urinating in the bathroom,he fell on his knees,no LOC,No involuntary movements of UL/LL

Taken to outside hospital found out to be having BP-250/120mm of hg, antihypertensives were given

From 1 day pt is lethargic, decreased responsiveness, brought to our hospital for further evaluation.

On presentation to casualty BP:180/120mm hg f/b 170/100 f/b 160/100 and 150/80 mm hg

Past history:

K/C/O HTN since 2 years and on irregular medication,Not a K/C/O DM, Bronchial asthma,CAD

Family History:

No family history of HTN, DM, bronchial asthma, epilepsy

General examination:- 

Patient is conscious,coherent, cooperative,Oriented to time,place and person

No signs of pallor,icterus,cyanosis,lymphadenopathy&pedal edema

Vitals:

Temp:- 98.3 F

BP:- 180/120 mmhg

RR:- 20 cpm

PR:- 72 bpm

Systemic examination:-

CVS- S1, S2 heard,

RS:BAE present

CNS: 

          TONE      UL     LL

          Right   Normal Normal

          Left     Normal Normal

          POWER    UL    LL

           Right       4/5   4/5

           Left          4/5   4/5

           

        REFLEXES RIGHT LEFT

              B              +         + 

              T              +         +

              S             +          +

              K             +          +

              A             +          +

              P           Flexion Flexion

Gait:gait

Investigations:

ECG:

USG abdomen:Impression-No sonological abnormality detected

MRI BRAIN:

Impression:

1.Acute infarct in right putamen extending into  corona radiata,right posterior periventricular white matter

2.Diffuse  cerebral atrophy with small vessel ischaemic changes.

3.Few Old lacunar infarcts in both basal ganglia and left hemi pons and left precentral gyrus

Provisional Diagnosis:CVA with Acute infarct in putamen,globus pallidus on RT side 

With Hemorrhagic transformation Hypertensive urgency with

 K/C/O HTN since 2 years

Treatment:

1.BP MONITORING HOURLY

2.STRICT I/O CHARTING

SOAP

3.TAB.TELMA-H PO OD

SOAP notes day 1:

S- C/O Giddiness reduced compared to yesterday

 C/O Generalized weakness

O-

O/E:Pt-C/C/C

Temp:Afebrile

PR:84bpm

BP:160/100 mm of hg

RR:18cpm

CVS:S1,S2 heard,no murmurs

RS:BAE+,NVBS heard

P/A:Soft,non tender

CNS: 

E4V5M6

          TONE UL LL

          Right Normal Normal

          Left Normal Normal

          POWER UL LL

           Right 4/5 4/5

           Left 4/5 4/5

           

        REFLEXES RIGHT         LEFT

                           +                    + 

              T           +                    +

              S          +                     +

              K          +                     +

              A          +                     +

              P        Flexion       Flexion

              

A:CVA with Acute infarct in putamen,globus pallidus on RT side 

With Hemorrhagic transformation Hypertensive urgency with

 K/C/O HTN since 2 years

P:

1.BP MONITORING HOURLY

2.STRICT I/O CHARTING

3.TAB.TELMA-H PO OD

SOAP notes day 2

ICU bed 2

06/03/2022

S- No C/O Giddiness 

 C/O Generalized weakness

O-

O/E:Pt-C/C/C

Temp:Afebrile

PR:90bpm

BP:130/90 mm of hg

RR:18cpm

CVS:S1,S2 heard,no murmurs

RS:BAE+,NVBS heard

P/A:Soft,non tender

CNS: 

E4V5M6

          TONE UL LL

          Right Normal Normal

          Left Normal Normal

          POWER UL LL

           Right 4/5 4/5

           Left 4/5 4/5

           

        REFLEXES RIGHT. LEFT

              B + + 

              T + +

              S + +

              K + +

              A + +

              P Flexion Flexion

              

A:Acute CVA(AIS in right putamen,globus pallidus) with Hypertensive urgency(Resolved) with

 K/C/O HTN since 2 years

P:

1.BP MONITORING HOURLY

2.STRICT I/O CHARTING

3.TAB.TELMA-H PO OD

4.TAB.ECOSPIRIN 150MG PO OD

5.TAB.CLOPITAS 75MG PO OD

SOAP notes day 3

Ward

07/03/2022

S- No C/O Giddiness 

 C/O Generalized weakness

O-

O/E:Pt-C/C/C

Temp:Afebrile

PR:86bpm

BP:110/90 mm of hg

RR:18cpm

CVS:S1,S2 heard,no murmurs

RS:BAE+,NVBS heard

P/A:Soft,non tender

CNS: 

E4V5M6

          TONE UL LL

          Right Normal Normal

          Left Normal Normal

          POWER UL LL

           Right 4/5 4/5

           Left 4/5 4/5

           

        REFLEXES RIGHT. LEFT

              B + + 

              T + +

              S + +

              K + +

              A + +

              P Flexion Flexion

              

A:Acute CVA(AIS in right putamen,globus pallidus) with Hypertensive urgency(Resolved) with

 K/C/O HTN since 2 years

P:

1.BP MONITORING HOURLY

2.STRICT I/O CHARTING

3.TAB.TELMA-H PO OD

4.TAB.ECOSPIRIN 150MG PO OD

5.TAB.CLOPITAS 75MG PO OD