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A CASE DISCUSSION OF 60/M ON ACUTE CVA HEAMORRHAGIC CVA PRESENTED WITH HTN EMERGENCY; RIGHT SIDED HEMIPLEGIA K/C/O HTN ON IRREGULAR MEDICATION

 This is online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputsThis e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.


A 60 yr old gentle man came to casuality with CHEIF COMPLAINTS of difficulty in walking,  inability to speek and unable to move Right hand and Right leg 

HISTORY OF PRESENT ILLNESS : 
Pt was apparently normal until 1 yr back then he had fever for which he went to RMP and diagnosed to have hypertension ,but used medication only on giddiness episode (ie.., not on regular medication) 


PAST HISTORY: 
30 yrs back he had abdominal pain and diagnosed to have appendicitis, for which he underwent appendicectomy
25 yrs back , while he was at farm in the day time, suddenly he had he fell down , he had paralysis of right leg , for which pt was taken to Kurnool , there at some hospital they gave some medications and then they had their cultural beliefs and stayed for some days in temple and did Pooja for his recovery , after that they returned to their home , pt couldn’t walk and he took rest for about 4 months and then he started walking with support of stick , finally when pt thought he could walk without support he back to farm
3 yrs back , he had h/o RTA and sustained shaft of femur fracture, for which surgery was done and there is implant inserted 

OCCUAPATIONAL HISTORY:
He was farmer from his 20 yrs of age ( 40 yrs back ) , after that from his 40 yrs ( 20 yrs back ) he is working as a security guard in Hyderabad  till his recent fracture incident , from then he is not doing any work.

ALCOHOLIC HISTORY: 
He started taking alcohol from 40 yrs ( when his age is 20 yrs ) initially he used to take daily Natu Sara as mentioned above , then he started taking quarter daily after Sara has been banned .He mostly prefers drinking alone on regular days & with their relatives on festivals , functions, family gatherings 
But after the fracture incident he stopped drinking daily but he drinks 2/3 times a week 

SMOKING HISTORY:
He started smoking BIDI 1 pack/ day since 40 yrs ( when his age is 20 yrs ) and he continues to smoke till date ; he didn’t  decrease smoking after his accident; in this way it is different from the alcohol history 

MEDICAL HISTORY:

* He is K/c/o HTN and is on irregular medication from 1 yr 

Not a K/C/O asthma / Ischemic heart disease / epilepsy / TB / DM

FAMILY HISTORY

No significant family history 

PERSONAL HISTORY 

OCCUPATION : retired security guard

DIET : Mixed 

APPETITE : Normal 

SLEEP : Normal

BOWEL AND BLADDER HABITS : Normal

ADDICTIONS: alcohol (90/180ml per day) and bidi addiction (1 pack - 20 per day ) 

GENERAL EXAMINATION 

* Patient is concious 

* Built - moderately built , moderately nourished 

VITALS 

Blood pressure : 180/100 mm hg

Pulse Rate : 51 bpm
 
RR :  17cpm

Temperature  : 98.7 degrees  F

SPO2 : 91% under 8L of O2

GCS : E4V1M1

* NO PALLOR,ICTERUS , CYANOSIS, CLUBBING , LYMPHADENOPATHY ,EDEMA









SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM :

Inspection : bilateral symmetrical chestPalpation: trachea centrally placed, bilateral symmetrical chest movements 

Percussion: resonance

Auscultation: Bilateral air entry is present , NVBS , no adventitious sounds heard

PER ABDOMEN :

Inspection: obese

Palpation :soft non tender

Auscultation: bowel sounds heard

Percussion: resonant note

CVS: 

S1 S2 heard, JVP not rised

CNS: 

speech absent

                   RT   LT

Tone : UL  N    N

             LL  N    N

Power : UL 0/5 5/5

               LL 5/5 5/5

 MSE : not elicitable

 Reflexs : 

       B   T   S  K   A            P

 Rt  ++.                       Extensor

 Lt      Absent             Extensor


INVESTIGATIONS









MRI IMAGES















CT BRAIN VIDEO LINK :

https://youtube.com/shorts/ywvVc8dmIho?feature=share

DIAGNOSIS : 
ACUTE CVA (HEAMORRHAGIC) WITH RIGHT SIDED HEMIPLEGIA K/C/O HTN ON IRREGULAR MEDICATION 

TREATMENT :

IVF NS @ 100 ml/hr
Tab.paracetamol 650 mg po/sos
Inj.Leviteracetam 500 mg in 100 ml Ns Iv 
Inj.Mannitol over 10-15 mins tid
Tab.Nicardia retard 10 mg tid
Inj. Optineuron Iv/od
 Bp monitoring and GCS monitoring hrly
 Monitor vitals & temp charting and inform sos
Physiotherapy for both upper and lower limbs 
Inj.pitaz 4.5 g tid
Hrly oral suction

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