75/F with altered sensorium

75/F
Patient was brought to the casualty in an altered sensorium 3pm yesterday 

History of present illness:-

Patient was apparently normal until 3pm yesterday(19/10/2023).
She then became altered since 3pm yesterday and started speaking random words, not answering revelantly and without deviation of mouth with weakness of right upper limb and right lower limb.
Associated with involuntary micturition and slurring of speech
No C/O loss of consciousness, seizures, headache, involuntary defecation, vomitings, fever, trauma, diplopia.

History of past illness:-
H/o CVA with right sided hemiparesis 3 years back , recovered now
K/C/O Hypertension since 4 years ( not using medication regularly in past few days)
N/K/C/O DM,TB,Epilepsy,CAD,Thyroid disorders,Bronchial asthma

Personal history:-
Diet - Mixed
Appetite - Normal
Bowel and bladder - regular
Sleep - adequate
No addictions
No H/o food and drug allergies

Family history:-
Not significant 

General examination:-
Patient Patient is conscious, coherent, cooperative ,moderately built and nourished

No signs of pallor, icterus, cyanosis, clubbing, generalised lymphadenopathy

Temp- 97.8F
BP-150/90 mmHg
PR- 68 bpm
RR - 18cpm
SpO2- 97%

Systemic examination :
CVS- S1;S2 + , no murmors
RS- BAE+ NVBS heard
P/A- Soft non tender, no organomegaly
CNS :- 
Patient is arousable 
No signs of meningeal irritation

Tone:
Right Left
UL Increased Increased 
LL Increased Increased

Power:
Right Left
UL 2/5 3/5
LL 2/5 3/5

Reflexes-
Biceps 3+ 3+
Triceps 3+ 3+
Supinator 2+ 2+
Knee 3+ 3+
Plantar extension extension


DIAGNOSIS-
Reccurent CVA with Right hemiparesis with hemorrhagic infarct in left fronto-parietal region with altered sensorium with K/C/O CVA ( Right hemiparesis 3years back) with K/C/O Hypertension since 4years(Non compliance to drugs)

Treatment-
IV fluids NS @ 50ml/ hr
Inj. Levipil 500mg PO/bd
Tab.Nitrofurantoin 100mg po/bd
Tab.Atorvas 20mg po/hs
Tab.Amlodipine 10mg po/od
Syp.glycerol 30ml po/tid
GRBS 4th hourly monitoring
Vitals monitoring hourly 
Inform SOS


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