CEREBRO VASCULAR ATTACK

Submitted by
v.Kalyan babu
Y15PHD0322
ABSTRACT
A 35 years old male patient came with complaints of Lt UL/LL
weakness,slurred speech,facial weakness. O/E pt was
drowsy,arousable,following commands his pupil:NSRl(+),Lt
hemipherisis,ataxia,rt UL/LL:5/5 and lt LL/UL:3/5.investigations were
done.CT scan of brain showed acute infract in Rt-ACA-MCA-PCA
watershed territory.MRA showed stenosis of B/L distal MCA.he was
treated
anticoagulants,antiplatelets,antibiotics,statins,antacids,nuero protective
drugs.
SUBJECTIVE EVIDENCE
A 53 years old male patient admitted in hospital with chief
complaints of
Left upper limb and lower limb weakness since 4 days
Dysarthria
Decreased vision on both eyes
OBJECTIVE EVIDENCE
Lab investigations
parameter Observed value Reference range
Hemoglobin 16.0 11.5-16.5 g/dl
Total RBC 6.3 3.8-6 millions/cumm
Total WBC 9700 4000-11000 cells/cumm
nuetrophils 57 40-70%
lymphocytes 36 20-45%
PCV 58.5 42-52%
MCV 93 80-94 cubic microns
MCH 31.7 28-32 millions/cumm
ESR 01 1-20 mm/hr
Prothrombin time 25.1 11.6-15.5
Platelet count 3.30 1.5-4.5 lacks/cumm
Serum triglycerides 230 0.1-200mg/dl
Serum pottasium 4.2 .34-4.5 mmol/lit
OTHER INVESTIGATIONS
MRA:stenosis of B/L distal MCA
MRI and CT scan:acute infract in rt ACA-MCA-PCA
watershed territory
Echo: PFO with L-R shunt,EF:60%
DAY NOTES
Day-1 Day-2
pt consious,coherent b/l pupil(+) pt consious,coherent b/l pupil(+)
Left homonymous heminopia(+) Left homonymous heminopia(+)
Cvs:s1s2(+) Cvs:s1s2(+)
Lungs:B/L AE(+) Lungs:B/L AE(+)
BP:130/80 mmHg BP:110/90mmHg
PR:75bpm PR:65bpm
RR:20 cpm RR:22cpm
Spo2:99% Spo2:99%
Day-3 Day-4
pt consious,coherent b/l pupil(+) pt consious,coherent b/l pupil(+)
Left homonymous heminopia(+) Left homonymous heminopia(+)
Mild facial weakness Mild dysarthria
Mild dysarthria Mild facial weakness
Cvs:s1s2(+) Cvs:s1s2(+)
Lungs:B/L AE(+) Lungs:B/L AE(+)
BP:130/80 mmHg BP:130/80 mmHg
PR:84bpm PR:80bpm
RR:20 cpm RR:20 cpm
Spo2:99% Spo2:99%
Left UL-1/5 Left UL-2/5
LL-3/5 LL-4/5
Day-3 Day-3
pt consious,coherent b/l pupil(+) pt consious,coherent b/l pupil(+)
Left homonymous heminopia(+) Left homonymous heminopia(+)
Mild facial weakness Mild facial weakness
Mild dysarthria No fresh complaints
Cvs:s1s2(+) Cvs:s1s2(+)
Lungs:B/L AE(+) Lungs:B/L AE(+)
BP:130/70 mmHg BP:130/70 mmHg
PR:73bpm PR:70bpm
RR:20 cpm RR:20 cpm
Spo2:99% Spo2:99%
Left UL-3/5 Left UL-3/5
LL-4/5 LL-4/5
Grip(+)
TREATMENT CHART
Brand Drug dose RoA freq D D D D D D
1 2 3 4 5 6
dispirin aspirin 325mg po 1-1-1      

T.atocor Atorvastatin 80mg po 0-0-1      

T.homai Methyl po 0-1-0      

cobalamine
inj.thiamine thiamine 100mg IV 1-1-1      

t.pantop pantaprazole 40mg po 1-0-1    

t.librium Chlordiazepoxide 10mg po 1-0-1      

t.cerecetum piracetum 800mg po 1-0-1      

t.rantac ranitidine 150mg po 1-0-1  

Inj.heparin heparin SC 1-0-1      

ASSESMENT

From the above subjective and objective evidence the pt

was diagnosed with cerebro vascular attack(watershed
infract) and treated with appropriate medication and
supportive care.

Untreated indication
pt complaints about shoulder pain
Resolution
Diclofenac 100mg is given to patient orally.