55 YEAR OLD MALE WITH GIDDINESS AND LETHARGY

55Y/M with Giddiness and lethargy

55 year old male painter by occupation came to casualty with cheif complaints of 

1.Giddiness since 2 days

2.lethargy since 1 day

- Patient was apparently alright 2 days back then at 9:00 am he had sudden episode of giddiness while urinating in the bathroom where he fell down on his knees, no LOC,No involuntary movements of UL/LL.

- He was taken to outside hospital found out to be having BP-250/120mm of hgand so  antihypertensives were given.

- from  day 1 patient was brought  here with lethargy,  decreased responsiveness for further evaluation.

- On presentation to casualty , he had 

 BP: 180/120mm hg f/b 170/100 f/b 160/100 and 150/80 mm hg.

Past history:

K/C/O HTN since 2 years and on irregular medication,

~Not a K/C/O DM, Bronchial asthma,CAD.

Family History

No family history of HTN, DM, bronchial asthma, epilepsy.

General examination:- 

- Patient is conscious,coherent, cooperative,oriented to time,place and person.

- No signs pallor,icterus,cyanosis,lymphadenopathy&pedal edema

Vitals:

Temp:- 98.3 F

BP:- 180/120 mmhg

RR:- 20 cpm

PR:- 72 bpm

Systemic examination:-

CVS- S1, S2 heard,

RS:BAE present

CNS: 

          TONE      UL     LL

          Right   Normal Normal

          Left     Normal Normal

          POWER    UL    LL

           Right       4/5   4/5

           Left          4/5   4/5

           

        REFLEXES

                           RIGHT LEFT

              B              +         + 

              T              +         +

              S             +          +

              K             +          +

              A             +          +

              P           Flexion Flexion

Gait: https://youtu.be/-uRgLAvGvPc

Investigations:

MRI BRAIN(PROVISIONAL):

Impression:

1.Acute infarct in putamen,globus pallidus on RT side which shows blooming on SWI-Likely Hemorrhagic transformation

2.Old infarct in left side of pons

3.B/L periventricular hyperintensities on T2/FLAIR-S/O small vessel ischaemic changes.

Diagnosis:CVA with Acute infarct in putamen,globus pallidus on RT side 

With Hemorrhagic transformation Hypertensive urgency with

 K/C/O HTN since 2 years.

Treatment:

1.BP MONITORING HOURLY

2.STRICT I/O CHARTING

3.TAB.TELMA-H PO OD

 Day 1:

S- C/O Giddiness reduced compared to yesterday

 C/O Generalized weakness

O-O/E: Pt-C/C/C

Temp:Afebrile

PR:84bpm

BP:160/100 mm of hg

RR:18cpm

CVS:S1,S2 heard,no murmurs

RS:BAE+,NVBS heard

P/A:Soft,non tender

CNS: 

E4V5M6

          TONE   UL           LL

          Right   Normal    Normal

          Left     Normal    Normal

          POWER   UL         LL

           Right.    4/5       4/5

           Left        4/5      4/5

           

        REFLEXES RIGHT  LEFT

              B.             +          + 

              T              +          +

              S              +          +

              K              +         +

              A              +         +

              P          Flexion    Flexion

              

A:  CVA with Acute infarct in  putamen,globus pallidus on RT side 

with Hemorrhagic transformation Hypertensive urgency with

 K/C/O HTN since 2 years

P:

1.BP MONITORING HOURLY

2.STRICT I/O CHARTING

3.TAB.TELMA-H PO OD