55 year male with Giddiness and Lethargy
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Complaints
USG abdomen : Impression No serological abnormality detected.
MRI brain :
Diagnosis :
55 year male painter by occupation came with chief complaints of
Giddiness since 2 days
Lethargy since 1 day
Patient was apparently asymptomatic two days back then at 9:00am patient had sudden episode of giddiness while urinating in the bathroom,he fell on his knees ,no loc,no involuntary movements of UL/LL.
HOPI :
Taken to outside hospital found out to be having bp 250/120 mmHg
Antihypertensive were given from one day patients Lethargy decreased, responsiveness brought to our hospital for further evaluation.
On presentation to casuality Bp 180/120mmHg ,170/110 mmHg, 160/70 mmHg,
150/80 mmHg.
Past history:
Known case of HTN since 2 years and on irregular medications
No Diabetes,CAD, Asthama,TB, Epilepsy.
Personal history :
Married
Occupation: painter
Appetite : normal
Non veg
Bowel and Bladder movements : regular
Micturation : normal
Tobacco smoking one pack beedie
Family history :
No family history of HTN, DM, Bronchial Asthma, Epilepsy.
General examination :
Patient is conscious, coherent, cooperative , well oriented to time , place,and person.
No signs of pallor, icterus, cyanosis, lymphadenopathy,pedal edema.
Vitals:
Temperature: 98.3 degree F
Bp : 180/120mmHg
RR : 20cpm
PR : 72 bom
Systemic examination :
CVS cardiac sounds : S1 and S2 heard
No thrills
No cardiac murmurs
Respiratory system :
No dyspnoea,
No wheezing
Position of trachea : central
Vesicular breath sounds present.
Abdomen:
No tenderness ,No palpable mass ,hernial orifice normal ,no free fluid ,no bruits ,liver non palpable ,spleen non palpable ,
Bowel sounds present.
Genitals, speculum examination, PV examination,PR examination are all normal.
CNS :
level of consciousness : conscious
Speech : normal
Tone : normal
Investigation :
ECG
Impression
1. Acute infarct in Rt.putamen extending in to corona radiata,rt posterior peri ventricular white matter.
2. Diffuse cerebral atrophy with small vessel , ischemic changes.
3. Few old lacunar infarcts in both basal ganglia and left hemi pons and left precentral gyrus.
CVA with acute infarct in putamen,Globus pallidus on right side with hemorrhagic transformation Hypertensive urgency with known case of HTN since 2 years.
Treatment :
Bp monitoring hourly
Strict I/O charting.
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