78 yr old with left hemiparesis



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79 years old female patient was brought to the casuality withthe chief complaints of 
weakness of left upper and lower limb since 4 days 
Deviation of mouth towards left since 4 days
Unresponsive since 1 day

History of present illness
 Patient was apparently asymptomatic 9 years back then she developed generalized weakness also fatigability following which she reached nearest medical center and was diagnosed with Hypertension and Diabetes Mellitus and used regular medication.
6 months back she had a history severe headache following which on imaging diagnosed with small vessel infract.
4 days back she developed transient deviation of mouth to left following it was reversed spontaneously after few min to hours and slowly became unresponsive 


Past History
Known case of Diabetes Mellitus and Hypertension since 9 years for which she was taking Metformin 500mg and Telma 40mg 

Personal history
Diet: mixed
Apetite: Normal
Sleep: Adequate
Bowel and bladder movements:Regular
Addictions: no
Allergies: None

On Examination
Patient was conscious but unresponsive, not co operative, not coherent
Vitals
Bp 135/90mmhg
PR 104 BPM
SpO2 83 
Temperature afebrile



General examination
No pallor
No icterus
No clubbing
No cynosis
No generalised lymphadenopathy
No bilateral pedal oedema.

Local examination 

CNS 

Patient was stuporous
Speech no response
GCS 3/15 E1V1M1
Tone.     R            L
UL.         N           Decreased
LL.         N           Decreased
Power
UL.        4/5.           1/5
LL.        4/5.           1/5
Reflexes absent
Biceps
Triceps
Supinator
Knee ankle
RESPIRATORY SYSTEM:Normal vesicular breath sounds heard 
CVS:S1 and S2 heard.No added murmurs.
PER ABDOMEN:Soft and non tender.No organomegaly 

 
Investigations 

















2D Echo showing ASD which might cause Paradoxical emboli causes Embolic Stroke




Provisional Diagnosis


RIGHT SIDED CEREBROVASCULAR ACCIDENT INVOLVING CORTEX , TEMPORAL & PARITAL LOBE (ACUTE INFARCT IN LEFT MCA TERRITORY 


Treatment


Day 1


1 INJ THIAMINE 1 AMP IN 100 ML NS

2 TAB PAN 40 MG IV/OD

3 TAB ECOSPIRIN 75 MG RQ/OD 

4 TAB ATORVAS 40 MG RQ/OD

5 TAB CLOPITAB 75 MG RQ/OD

6 IVF  NS OR RL UO + 50 ML / HR

7 NEBULIZER WITH

    . Mucomist 6 HOURLY

    . Budecort  6  HOURLY


PATIENT HAS 3 EPISODES OF PSVT 

@ 1 am , 3 am , 6 am which is treated with ADENOSINE


Day 2 

1 INJ THIAMINE 1 AMP IN 100 ML NS

2 TAB PAN 40 MG IV/OD

3 TAB ECOSPIRIN 75 MG RQ/OD 

4 TAB ATORVAS 40 MG RQ/OD

5 TAB CLOPITAB 75 MG RQ/OD

6 IVF NS OR RL UO + 50 ML / HR

7 NEBULIZER WITH

    . Mucomist 6 HOURLY

    . Budecort 6 HOURLY

8 Adenosine infusion was continued


Day 3 

Same medication followed...

At 12 pm

No recordable PR

BP-NR 

SPO2-60% MRA


CPR was initiated Acc. to 2015 AHA guidelines 

6 cycles of cpr was done and patient was still unresponsive 

And was declared dead 

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