75 YRS OLD FEMALE WITH CVA

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Team:

Interns-

M Supriya

Mohitha

K Sowmya

Sanjay

Amrutha

Dr.Druga Krishna PGY1

Dr.Ajith Kumar PGY2

Dr.Laxma Reddy PGY3

Dr.Manasa PGY3

Dr.Vijaya Lakshmi (Ast.Prof.)

C / o altered sensorium 

Unable to speak

Unable to move her upper and lower Limbs since  6 o'clock in the evening yesterday

Patient had history of toddy intake in the afternoon yesterday after which she unable to move her right upper limb and lower Limbs ⁶6ťshe unable to speak ok or response two daughters commands six o'clock in the evening yesterday then she was taken to to local Hos6pital where inhalation and cough syrup was given following which she was referred to KIMS for further evaluation

Past history

No  H/ o DM,HTN,CVA,ASTHMA,76TB,EPILEPSY 

Personal history 

 Toddy drinker daily

-General examination:-

pt was unconscious

pt was thin built 

No signs of Icterus, cynosis,clubbing lymphedenopathy, Generalized edema 

GCS:-E1V1M5

CNS-

Higher mental functions-cant be elicited 

Cranial nerves-cant be elicited

motor system-.                    R.                      L.   

power                  UL-.          1/5.              4/5.    

                            LL-.           2/5.              4/5.  

 Tone-.                 UL-.     Hypotonic      Hypertonic

                            LL-.       Hypotonic      Hypertonic

reflexes-.                                   R.                      L.   

                biceps-.                     1+.                   1+.  

                triceps-.                    -                      -

                supinator-.                -                       -

                knee.                          -                      1+

               ankle-.                         -                        -

               plantar -          extension             extension

Sensory system-cant be elicited 

Cerebellar functions-cant be elicited  

Cvs:-s1,s2+

R/s:-BAE+

P/A:-soft,no organomegaly 

Treatment:-

On the day of admission 

1.inj.CEFTRIAONE 1gm/IV/BD

2.inj.OPTINEURON 1amp in 100ml NS/IV/OD

2.inj.PAN 40mg IV/OD

DAY 2

1.TAB ASPIRIN 75MG OD/PO

2.TAB ATORVASTATIN 40MG OD H/S

3.INJ.CEFTRIOXONE 1GM IV/BD

4.INJ.PAN 40 MG IV/OD

5.INJ OPTINEURON 1 AMP IN 100ML NS IV/BD

Day 3

1.TAB ASPIRIN 75MG OD/PO

2.TAB ATORVASTATIN 40MG OD H/S

3.INJ.CEFTRIOXONE 1GM IV/BD

4.INJ.PAN 40 MG IV/OD

5.INJ OPTINEURON 1 AMP IN 100ML NS IV/BD

pt was shifted to air bed to prevent bedsores