A CASE OF CEREBROVASCULAR ACCIDENT


MEDICINE CASE DISCUSSION

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

I have been given this case, in an attempt to solve and understand the topic of "Patient's clinical data analysis”. This has helped me develop my competency in reading and comprehending clinical data including history taking, clinical findings and investigations. The goal is to come up with a diagnosis and treatment plan.  

PAVITRA BALDAWA  

ROLL NUMBER -104

24th MAY, 2021

CASE DISCUSSION

Chief complaints: 

A 60-year-old female who is a daily wage worker by occupation came to the causality OPD on 1st may 2021 with chief complaints of loss of consciousness (altered sensorium) for 30mins to 60 mins.

History of presenting illness:

The patient was apparently asymptomatic the morning she came to the OPD, when she suddenly fell after getting out of bathroom, it was associated with loss of consciousness for 30min to 1 hour, the patient was taken to a local hospital and was said to have high blood pressure and was given tab. Depin 5mg.Patient had involuntary micturition while unconscious.

No history of seizures, vomiting, fever.

Patient presented with slurring speech.

Past history:

Patient is not a known case of hypertension, diabetes mellitus, epilepsy, asthma, tuberculosis or CAD

No similar complains in the past

Personal history:

Diet-mixed

Appetite-normal

Sleep-adequate

Bowel movements-regular

Bladder -involuntary micturition

Addictions-occasional consumption of alcohol

Allergies-no food and drug allergies

Drug history:

Patient was given tab.depin 5mg before coming to the OPD by a doctor at local hospital

No known drug allergies

Family history:

Insignificant

General examination:

Examination was done by a valid consent from the attender in daytime under proper sunlight and a well-ventilated room.

The patient was stuporous and not cooperative but coherent. The patient was well nourished ,moderately build and  not oriented to time ,place and person .

VITALS:

Pulse rate-102bpm

Bp-130/80mmhg

Respiratory rate- 20cpm

Temperature-Afebrile

GCS-4/15

GRBS-232mg/dl

Spo2-99% at room air

Pallor: Absent

Icterus: Absent

Cyanosis: Absent

Clubbing: Absent

Koilonychia: Absent

Generalized lymphadenopathy: Absent

Oedema: Absent 

Pupils: Mild dilated ,slow reaction to light.

Systemic examination:

Respiratory system-

·       Bilateral air entry positive

Cardiovascular system-

·       S1 and S2 are normal

·       No abnormal heart sounds are heard

Central nervous system-

·       level of consciousness-stuporous

·       Speech-slurred

 ●       No signs of meningeal infection or irritation

·       GCS-4/15

 Per abdomen examination-

·       Soft and non-tender ,bowel sounds heard

Investigations

CT-scan- acute haemorrhage in left cerebral hemisphere. Evidence of extension of haemorrhage into 3rd ,4th and lateral ventricles.

                                            





Treatment given-:

Monitoring of vitals

Head end evaluation

Referral to higher centre:

Patient was referred to the higher centre in need of neurosurgery intervention,

Advice at discharge:

Patient’s condition has been explained to the patient attenders in their own understandable language and need for neuro surgery intervention has also been explained .

In case of emergency immediately contact your consultant, doctor or attend emergency department

Preventive care- avoid self-medication without doctor’s advice. Do not miss any medication.



I would like to thank Rakesh Biswas Sir for providing us this opportunity.

Thank you Saicharan kulakarni sir for guiding me.


QUESTIONS


What are the most common etiology related to CVA?

What are the other treatment modality?

Does physiotherapy play a role ?

Describe the neurosurgery intervention in this case?

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