60 YR MALE WITH ACUTE STROKE

60yr male came with C/o irrelevant talk since 10 days, altered sensorium since 10 days

No c/o limb weakness, seizures,headache,fever,vomitings, loose stools

Pt was apparently normal and went to work on 12/12/21 and slept at night, on 13/12/21 after waking up pt was wandering aimlessly at house and was talking irrelevantly was taken to outside hospital 2 days later and was diagnosed with acute infract Rt Fronto temporo parietal region, was admitted and treated for the same.

C/o hallucinations after admitting in hospital.

MR venogram was done today morning superior saggital sinus thrombosis

S/P PTCA (2° to CAD) in 2016

H/o giddiness 2yrs ago diagnosed with CVA (Lt cerebellar infract)

Denovo HTN (not on any medication)

Known smoker daily since 15 yrs 1pack/day

Known alcoholic daily since 10yrs 90-180ml/day

O/E :

Pt c/c/c

Pallor+

No Icterus/cyanosis/clubbing/koilonychia/lymphadenopathy/pedal edema

Temp- 98 f 

PR- 93 bpm

BP- 190/110 mmhg

Grbs- 88mg/dl

CVS - S1 S2 +

RS- BAE+,NVBS

P/A - SOFT, NT

CNS-

GCS-E4V3M6

Pupils- B/l nsrl

Not oriented to time/place/person

Not obeying commands 

Irrelevant speech+

No signs of Meningeal irritation

Motor system- 

Power- 5/5 in all limbs

Tone increased in all 4 limbs 

Reflexes      Rt         Lt

 Biceps        3+        2+

 Triceps       3+        2+

 Supinator   3+        2+

  Knee          3+        3+

  Ankle         2+        2+ 

  Plantar    mute    flexion

Cranial nerves- intact

Diagnosis:

 ACUTE INFRACT RT FRONTO TEMPORO PARIETAL REGION ?CARDIOEMBOLIC SYROKE

Denovo HTN

?alcohol withdrawal delirium

Rx:

TAB.ECOSPIRIN 150mg PO OD
Tab.CLOPITAB 75mg PO OD
Tab.ATORVAS 40 mg PO H/S
Tab.MET-XL 25 mg PO OD
Tab.AMLONG 5 mg PO OD
Tab.RISPERIDONE 0.5mg PO OD
Tab.OLANZEPINE 5 mg H/S
Tab.LORAZEPAM 2 mg SOS
Tab.AUGMENTIN 625mg PO BD ×5days
Tab.PAN 40mg PO OD
Tab.CHYMORAL FORTE PO TID
BP/SpO2/PR Monitoring 2nd hourly
GRBS charting 12th hourly