Acute Ischemic shock
A 70 yr old male came to hospital with complaint of weakness in right upper and lower limb since 3 days.
HISTORY OF PRESENT ILLNESS :
Patient was apparently asymptomatic 3years back when he has his first episode of right sided upper and lower limb weakness and was managed conservatively .
Then he again had his second episode of right side UL and LL weakness 1year back
Managed conservatively.
HISTORY OF PAST ILLNESS :
Patient is having hypertension frm past 1year.
No diabetes mellitus
No TB
No epilepsy
No asthma .
PERSONAL HISTORY :
Patient occupation is cattle grazer.
His appetite is normal
Mixed diet.
Bowel movements are regular.
Micturition is normal.
FAMILY HISTORY :
No significant history.
GENERAL EXAMINATION :
No pallor
No cyanosis
No lymphadenopathy
No oedema of feet
Temperature : Afebrile
Pulse rate : 70/min
Respiration rate : 16 /min
BP : 140 / 80 mm/Hg
spo2 : 98%
TREATMENT HISTORY :
PATIENT has BP since 1year and he is using atenolol 25mg since 1yr.
No diabetes
No asthma
SYESTEMIC EXAMINATION :
CVS :
S1 and S2 heard.
Respiration is normal .
CNS :
Patient is conscious
Speech : Patient is unable to speak but he is responding .
Reflexes are normal.
PROVISIONAL DIAGNOSIS :
Acute Ischemic shock
Right hemiplegia
Recurrent CVA
INVESTIGATIONS :
Ultrasound report :
ECG :
TREATMENT :
Tab.ecosprin 150mg
Tab .clopridogel 75mg
Tab.atorvastatin 40mg
Tab pancuronium 40mg
Tab atenolol 25mg
Physiotherapy of right UL and LL.
