CVA secondary to ischemic stroke.

 




A 45 year old female came to the casuality with involuntary movement and weakness in the right upper and lower limbs.

History of presenting illness:

The patient was apparently asymptomatic 5 years back when she had weakness of right sided upper and lower limbs - she wasn’t able to stand, had slurred speech and altered sensorium. At that time she wasn’t able to recognise anyone for 4-5 days and slowly started getting better. She used medication for 6 months. She was able to walk without support and do her regular chores. Her daughter noticed that she was dragging her leg while walking.

Again on 28-06-21, she complained of weakness in the right upper and lower limbs associated with involuntary movements and slurring of speech early in the morning for which she was brought to the casuality.

There was no history of involuntary micturition or loss of consiousness.

Past history:

Hypertension since 4 years, DM since 3 months - on medication. 

On examination,

The patient was consious, coherent, cooperative.

She had slurred speech.

Higher mental functions were normal.

All cranial nerves were intact.

Gait couldn’t be examined.

Motor system :

Bulk - Normal

Tone - Reduced on both limbs of right side. 

Power - 3/5 on right 4/5 on left

All upper and lower limb reflexes are absent on right side.

Finger nose coordination present.

Sensory system : Normal

Provisional diagnosis :

CVA secondary to ischemic stroke.

Investigations :
















Diagnosis :
CVA with acute infarct in left internal capsule and basal ganglia

Treatment :
Day 1 :
1. Tab. ASPIRIN (50mg) PO/OD
2. Tab. CLOPIDOGREL (75mg) PO/OD
3. Tab. ATORVAS (40mg) PO/OD
4. Inj. OPTINEURON 10mg in 100ml NS
5. Inj. HAI sc according to GRBS chart
6. Tab. CINOD 5mg PO/OD
Withhold antiHTN until further order

Day 2 :
1. Tab. ASPIRIN (50mg) PO/OD
2. Tab. CLOPIDOGREL (75mg) PO/OD
3. Tab. ATORVAS (40mg) PO/OD
4. Inj. OPTINEURON 10mg in 100ml NS
5. Inj. HAI sc according to GRBS chart
6. Tab. CINOD 5mg PO/OD

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