Right Lacunar Infarct
SK MAHBUBI
CHIEF COMPLAINTS:
C/O WEAKNESS OF RIGHT LOWER SINCE YESTERDAY AND VOMITINGS 2 EPISODES
HOPI:
PT WAS APPARENTLY ASYMPTOMATIC 1 DAY BACK THEN DEVELOPED WEAKNESS OF
RIGHT LOWER LIMB SUDDEN IN ONSET GRADUALLY PROGRESSIVE VOMITINGS 2
EPISODES WITH FOOD AS CONTENT NON PROJECTILE, NON BILIOUS, NOT ASSOCIATED
WITH DEVIATION OF MOUTH , DROOLING OF SALIVA NO LOSS OF WRINKLES ON FOREHEAD
, NO DIFFICULTY IN COMBING OF HAIR, MIXING FOOD, NO H/O INVOLUNTARY MICTURITION ,
NO H/O FALL OR TRAUMA
NO H/O INVOLUNTARY MOVEMENTS , HEADACHE
NO LOSS OF CONSCIOUSNESS, SLURRING OF SPEECH
PAST HISTORY:
K/C/O HTN SINCE 5 YEARS NOT USING MEDICATION
N/K/C/O DM2, CVA, CAD, ASTHMA, THYROID DISORDERS , SEIZURE EPISODES
PERSONAL HISTORY:
DIET: MIXED
SLEEP: ADEQUATE
BOWEL AND BLADDER MOVEMENTS: NORMAL
ALCOHOL: NO
SMOKING: NO
GENERAL EXAMINATION:
AFEBRILE.
PR: 103 BPM
BP: 240/120 MMHG.
RR: 18 CPM
SPO2: 98%
GRBS: 138 MG/DL
SYSTEMIC EXAMINATION:
CVS:S1, S2 +
RS:B/L AE+, NVBS.
P/A:SOFT, NON TENDER.
CNS: PUPILS RACTIVE.
PATIENT IS CONSCIOUS COHERANT AND COOPERATIVE WELL ORIENTED TO TIME ,
PERSON AND PLACE.
HANDEDNESS: RIGHT HANDED.
GCS: E4V5M6.
MEMORY:(IMMEDIATE, IMPLLICIT, LONGTERM)-INTACT.
CRANIAL NERVE EXAMINATION: NORMAL/
MOTOR SYSTEM:
BULK: NORMAL.
TONE: NORMAL
POWER: PROXIMAL DISTAL
RIGHT LEFT
UL LL UL LL
5/5 3/5 5/5 5/5
REFLEXES: RT LT
BICEPS 2+ 2+
TRICEPS 2+ 2+
SUPINATOR - -
ANKLE - +
KNEE - -
PLANTAR EXTENSOR FLEXOR
SENSORY SYSTEM: RT LT
FINE TOUCH N N
CRUDE TOUCH N N
PRESSURE INTACT INTACT
PAIN INTACT INTACT
VIBRATION INTACT INTACT
JOINT POSITION INTACT INTACT
GRAPHESTHESIA INTACT INTACT
2 POINT DISCRIMINATION INTACT INTACT
STEREOGNOSIS INTACT INTACT
TACTILE LOCALISATION INTACT INTACT
CEREBELLAR SIGNS:
FINGER NOSE TEST-INTACT
FINGER TO FINGER-INTACT
DYSDIDOKINESIA- NORMAL
HEEL-KNEE - NORMAL
ROMBERGS- NEGATIVE
OPHTHALMOLOGY REFERRAL WAS DONE I/V/O HYPERTENSIVE RETINOPATHY CHANGES
AND ? RAISED ICT , FUNDUS EXAMINATION COULDNOT BE DONE DUE TO POOR
DILATATION.
Diagnosis
ACUTE CVA ( RIGHT LACUNAR INFARCT )
K/C/O HTN SINCE 3 YEARS
COURSE IN HOSPITAL :
A 48 YEAR OLD FEMALE TAILOR BY OCCUPATION AND KNOWN CASE OF HYPERTENSION
SINCE 3 YEARS WAS ADMITTED IN THE HOSPITAL WITH THE COMPLAINTS OF WEAKNESS
OF RIGHT LOWER LIMB AND TINGLING OF RIGHT UPPER LIMB SINCE YESTERDAY NIGHT,
VOMITINGS 2 EPISODES AND WAS INVESTIGATED FURTHER AND ON EVALUATION AFTER
MRI SHOWED: TINY LESION OF BRIGHT SIGNAL ON DWI WITH NO CORRESPONDING
CHANGES IN ADC MAP NOTED IN RIGHT FRONTAL LOBE ; ? ARTEFACT; ? ACUTE TINY
LACUNAR INFARCT, AND WAS DIAGNOSED AS ACUTE CVA( RIGHT LACUNAR INFARCT); ON
ADMISSION HER BP WAS RECORDED AS 240/130 MMHG AND WAS MANAGED
CONSERVATIVELY WITH LABETALOL INFUSIONS FOR 2 DAYS(INCREASED AND DECREASED
ACCORDING TO BP), T.NICARDIA, INJ.LASIX , T.ASPIRIN , T.CLOPIDOGREL, T.ATORVASTATIN
AS STAT DOSES STARTED ON T.OLKEMTRIO ON DAY 2 AND PHYSIOTHERAPY SESSIONS
WERE DONE AND BP WAS MAINTED ON T.OLKEMTRIO AND T.CINOD.THE PATIENT
WEAKNESS IMPROVED AND BP WAS MAINTAINED.
PATIENT WAS HEMODYANAMICALLY STABLE AT THE TIME OF DISCHARGE.
Investigation
HEMOGRAM (4-3-24)
HB: 13.5
TLC: 15,100
PLT: 3.52
BLOOD UREA 27 mg/dl
SERUM CREATININE 0.9 mg/dl SERUM ELECTROLYTES (Na, K, C l)SODIUM 137 mEq/L
POTASSIUM 3.1 mEq/L CHLORIDE 97 mEq/L
LIVER FUNCTION TEST (LFT) Total Bilurubin 0.80 mg/dl Direct Bilurubin 0.16 mg/dl SGOT(AST) 27
IU/L SGPT(ALT) 19 IU/L ALKALINE PHOSPHATASE 172 IU/LTOTAL PROTEINS 8.1 gm/dl
ALBUMIN 4.5 gm/dl A/G RATIO 1.29
COMPLETE URINE EXAMINATION (CUE)
COLOUR Pale yellow
APPEARANCE Clear
REACTION Acidic
SP.GRAVITY 1.010
ALBUMIN +
SUGAR Nil
BILE SALTS Nil
BILE PIGMENTS Nil
PUS CELLS 4-5
EPITHELIAL CELLS 2-3
RED BLOOD CELLS Nil
CRYSTALS Nil
CASTS Nil
AMORPHOUS DEPOSITS Absent
OTHERS Nil
HEMOGRAM (6-3-24)
HB: 12.9
TLC: 12,800
PLT: 3.06
BLOOD UREA 26 mg/dl SERUM CREATININE 0.9 mg/dl
SERUM ELECTROLYTES (Na, K, C l)
SODIUM 141 mEq/L
POTASSIUM 4.2 mEq/L
CHLORIDE 103 mEq/L
HBsAg-RAPID NON REACTIVE
BLOOD UREA 50 mg/dl
SERUM CREATININE 1.0 mg/dl
SERUM ELECTROLYTES (Na, K, C l)
SODIUM 138 mEq/L
POTASSIUM 3.8 mEq/L
CHLORIDE 99mEq/L
HEMOGRAM (7-3-24)
HB: 12.6
TLC: 14,200
PLT: 3.2
2D ECHO IMPRESSION:
-MILD TR+/ NO PAH , TRIVIAL MR+, NO AR.
-NO RWMA SEVERE CONCENTRIC LVH+.
-GOOD LV SYSTOLIC FUNCTION.
-GRADE I DIASTOLIC DYSFUNCTION.
-NO PE/CLOTS.
MRI BRAIN WAS DONE ON 4/3/24 IMPRESSION:
-TINY LESION OF BRIGHT SIGNAL ON DWI WITH NO CORRESPONDING CHANGES IN ADC
MAP NOTED IN RIGHT FRONTAL LOBE
- ? ARTEFACT
? ACUTE TINY LACUNAR INFARCT.
-NO ABNORMALITY IN REST OF THE BRAIN.
Treatment Given(Enter only Generic Name):
TAB OLKEM-TRIO PO/OD
TAB CINOD 10MG PO/OD
TAB ECOSPIRIN GOLD 20MG PO/OD
TAB CITICHOLINE 500MG + TAB PIRACETAM 800MG PO/OD
TAB PREGABA-NT PO/HS
PHYSIOTHERAPHY OF RIGHT UPPER LIMBS AND LOWER LIMBS
Advice at Discharge
TAB OLKEM-TRIO PO/OD (CONTINUE)
TAB CINOD 10MG PO/OD (CONTINUE)
TAB ECOSPIRIN GOLD 20MG PO/OD (CONTINUE)
TAB CITICHOLINE 500MG + TAB PIRACETAM 800MG PO/OD (CONTINUE)
TAB PREGABA-NT PO/HS (CONTINUE)
PHYSIOTHERAPHY OF RIGHT UPPER LIMBS AND LOWER LIMBS
