CASE PRESENTATION

Stroke

By-Nagaraju B

Patient Name -xxxIP/OP No -309/13DOA - 1/4/13DOD - 5/4/13 Department - MedUnit -IIAge - 65yearsSex - MaleWeight -87kgs

SUBJECTIVEChief complaint/ History of Presenting illness: Patient c/o slurring of speech, confusion x 2 days weakness of right side since 1 day deviation of angle of mouth

Previous history:

k/c/o Hypertension x 6 years (Atenolol 50mg 1-0-0)Smokes 20 cigarettes/day x 20 years and

consumes 6 ounces wine/day x 25 years

PastMedicationHistory/Allergy:

Nothing significant

Personal history: Diet- MixedAppetite-NormalSleep-Slightly decreasedBowel –Constipation+Bladder- RegularHabits- Smoking, Alcoholism

Physical examination : patient was conscious but not responding to oral commands power: right upper limb - 2/5 & lower limb - 3/5

Vital signs: BP - 180/90mmHg PR – 60bpmRR – 18cpm Temp – afebrile

Family history: no f/h/o DM, HTN, Asthma, TB, Stroke, Epilepsy

OBJECTIVE

P[-], I[-], C[-], C[-], L[-], E[-]

Systems :P/A - soft, non tender RS - NVBS+, no additional sounds.

CVS – S1S2+, no murmurs

CNS – Motor Loss-Hemiplegia, Hemiparesis

Provisional diagnosis :? stroke

TEST TEST VALUE NORMAL VALUE

Hb (g/dl) 15.6 gm% 13-18

Total leucocytes counts (cells/cmm)

6000 4000-11000

N (%) 75% 40-75

L (%) 22% 20-45

E (%) 03% 1-6

M (%) 00% 2-10

B (%) 00% 0-1

Platelets (cells/cmm) 3Lac 1.5-4.0 lakh/cmm

ESR 10 0-17 mmhr

Urine Routine Sugar: Nil Albumin: Traces

Urine Microscopy Pc: 1-2 Ep: 1-2 cells

LABORATORY INVESTIGATIONS

TEST TEST VALUE NORMAL VALUE

Sr. Cr (mg/dl) 1.1 0.2-1.4mg/dl

GRBS 70 70-160mg/dl

Ser. Cl- 102 Up to 103 mEq/L

Ser. Na+ 136 136-145mmol/L

Ser. K+ 3.8 3.5-5.1 mmol/L

Total-C: 201 130-200mg/dl

HDL-C: 34 30-70mg/dl

LDL-C: 167 60-130mg/dl

VLDL: 24 5 – 40mg/dl

TG : 151 25- 160mg/dl

ECG ST segment elevation

CT-Scan Moderate sized, well defined hypo dense lesion in ganglion area

ASSESMENT

Based on the subjective & objective evidence the patient was diagnosed to have ischemic stroke.

BRAND NAME GENEROIC NAME

DOSE FREQUENCY

DATE DATE END

Kratol Inj mannitol 20% IV

100ml 1-1-1 1/4 4/4

Aten-50 Tab. Atenolol 50mg 1-0-0 1/4 Cont-

Stromix-A Tab.Clopidogrel+Aspirin

75/150mg

0-1-0 1/4 Cont-

Cholechek-10 T.Atorvastatin 10mg 0-0-1 1/4 Cont-

Nexpro-20 T.Esomeprazole magnesium

20mg 1-0-0 1/4 For 4 wk

Inj.Neurocetam Inj. Piracetam 200mg 2-2-1 1/4 4/4

Inj Nitroject Inj. Nitroglycerine

5mcg/min IV

1-2-2 1/4 4/4

Angispan-TR T.Nitroglycerin 6.5mg 1-0-1 5/4 For 4 wk

Piramet1200 T.Piracetam 1200mg 1-0-1 5/4 For 4 wk

MEDICATION CHART

DAY 1 BP : 180/90 mmHg PR: 60bpmO/E : Patient was conscious but not responding to oral commands power: right upper limb - 2/5

lower limb - 3/5

Others: ECG: ST segment elevation

ADV: Hb, TC, DC, PLT, RBS, SERUM Cr, UREA, ELECTROLITE,URINE ®, LIPID PROFILE, CT- SCAN

DAY 2 PULSE: 65 bpm

BP: 160/90mmhg O/E: Patient was conscious and was responding to oral commands. Advised to continue same treatment referred to physiotherapist

DAY 3

BP: 170/90 PULSE : 75bpm

Adv: Advised to continue the medication as such

DAY 4 BP:160/76mmHgPULSE : 80bpm O/E ; Patient feels better Power: 3/5 (UL)

4/5 (LL) Adv: Patient was advised to cst

DAY 5 BP: 140/90mmHgPULSE: 70bpm Adv: CST

Suggestion to Physician-

No drug interaction is found.

PLAN

Advice to patient-

Avoiding smoking Cutting down fat and cholesterol containing foods

to help reduce plaque build up Eating a healthy diet including plenty of fruits and

vegetables Limiting sodium in the diet, thereby reducing

blood pressure Exercising regularly Having 3 cup of green tea/ day Moderating alcohol intake Maintaining a normal weight Controlling blood pressure and keeping blood

sugars under control

THANK YOU…