CVA ACUTE HEMORHAGIC STROKE [RT HEMIPARESIS] WITH HYPERTENSIVE NEPHROPATHY WITH K/C/O HTN SINCE 30 YRS CVA 5 YRS BACK WITH H/O CVA 5 YRS BACK

 Case History and Clinical Findings

C/O RT LOWER LIMBS UPPER LIMBS WEAKNESS SINCE TODAY AFTERNOON

C/O DEVIATION OF MOUTH TOWARDS LEFT

LOSS OF CONSCIOUNESS SINCE SHOWN

PT WAS APPARENTLY ASYMPTOMATIC TILL TODAY THEN HAD DEVELOPED RT UPPER LIMB

AND OWER LIMB WEAKNESS WITH C/O DEVIATION OF MOUTH TOWARDS LEFT

N/K/C/O DM2 HTN CVA CAD EPILEPSY THYROID DISORDERS

H/O CVA 5 YRS BACK

OPTHAL REFERRAL WAS DONE I/V/O RIASED ICT AND HTN RETINOPATHY CHANGES

IMPRSSION - B/L EYES BROWN CATARACT WITH NO FUNDUS VIEW DUE TO LENTICULAR

OPACITY

O/E

PN ADMISSION -

DROWSY INCOHERENT

TEMP AFBRILE

BP 160/100 MMHG

PR - 88 BPM

RR - 22 CPM

CVS S1 S2 +

RS NVBS

PA SOFT AND NT

CNS

POWER RT UL 0/5 LL 0/5

POWER LT UL 3/5 LL 3/5

TONE RT UL INCREASED LL INCREASED

TONE LT UL NORMAL LL NORMAL

REFLEXES

RT B+++ T++ S+ K+++ A++

LT B+++ T++ S+ K+++ A++

ON DISCHARGE DAY:

PT IS C/C/C

TEMP AFBRILE

BP 140/80 MMHG

PR - 82 BPM

RR - 17 CPM

CNS NFND

PA SOFT AND NT

CVS S1 S2+

RS NVBS

Investigation

COMPLETE URINE EXAMINATION (CUE) 20-09-2023 07:45:PMCOLOURPale

yellowAPPEARANCEClearREACTIONAcidicSP.GRAVITY1.010ALBUMIN+++SUGARNilBILE

SALTSNilBILE PIGMENTSNilPUS CELLS4-5EPITHELIAL CELLS2-3RED BLOOD

CELLSNilCRYSTALSNilCASTSNilAMORPHOUS DEPOSITSAbsentOTHERSNilHBsAg-RAPID20-

09-2023 07:45:PMNegative RFT 20-09-2023 07:45:PMUREA30 mg/dl42-12 mg/dlCREATININE1.4

mg/dl1.1-0.6 mg/dlURIC ACID5.5 mg/dl6-2.6 mg/dlCALCIUM9.6 mg/dl10.2-8.6

mg/dlPHOSPHOROUS3.8 mg/dl4.5-2.5 mg/dlSODIUM143 mEq/L145-136 mEq/LPOTASSIUM4.1

mEq/L5.1-3.5 mEq/LCHLORIDE102 mEq/L98-107 mEq/LLIVER FUNCTION TEST (LFT) 20-09-2023

07:45:PMTotal Bilurubin0.89 mg/dl1-0 mg/dlDirect Bilurubin0.19 mg/dl0.2-0.0 mg/dlSGOT(AST)13

IU/L31-0 IU/LSGPT(ALT)10 IU/L34-0 IU/LALKALINE PHOSPHATE249 IU/L141-53 IU/LTOTAL

PROTEINS6.7 gm/dl8.3-6.4 gm/dlALBUMIN3.98 gm/dl4.6-3.2 gm/dlA/G RATIO1.46SERUM

ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 22-09-2023 01:38:AMSODIUM139

mEq/L145-136 mEq/LPOTASSIUM3.9 mEq/L5.1-3.5 mEq/LCHLORIDE102 mEq/L98-107

mEq/LCALCIUM IONIZED1.08 mmol/Lmmol/LSERUM ELECTROLYTES (Na, K, C l) AND SERUM

IONIZED CALCIUM 23-09-2023 01:26:AMSODIUM137 mEq/L145-136 mEq/LPOTASSIUM3.9

mEq/L5.1-3.5 mEq/LCHLORIDE98 mEq/L98-107 mEq/LCALCIUM IONIZED0.97 mmol/Lmmol/L

ECG NORMAL SINUS RHYTHM

MRI BRAINHYPER

ACUTE INTRA CRANIAL HEMORRHGES IN LEFT BAAL GANGLIA AND RT LENTIFORM

NUCLEUS

MICRO HEMORRHAGES IN B/L CEREBRAL HEMISPHERES

2 D ECHOCONCWENTRIC

LVH

EF = 63%

IVC SIZE 1.49 CMS AND NON COLLAPSING

DIAGNOSIS 

CVA ACUTE HEMORHAGIC STROKE [RT HEMIPARESIS] WITH HYPERTENSIVE

NEPHROPATHY WITH K/C/O HTN SINCE 30 YRS CVA 5 YRS BACK

WITH H/O CVA 5 YRS BACK

Treatment Given(Enter only Generic Name)

RT FEEDS:

100 ML WATER 2ND HRLY

100ML MILK 4TH HRLY

ORAL SUCTION 4TH HRLY

INJ MANNITOL 20% IV/BD

INJ LABETELOL 5MG IV/STAT

TAB CLINIDIPINE 10 MG RT/BD

Advice at Discharge

TAB CILINDIPINE/TELMISARTAN(10/40)MG PO/OD

PROTEIN RICH DIET


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