A 65 year old female came with c/o giddiness followed by fall on 23/09/23

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A 65 year old female came with the c/o giddiness followed by fall on 30/09/23. 

Patient was apparently asymptomatic 4 days back and then developed giddiness followed by fall and then developed slurring of speech associated with weakness of left upper and lower limb since then ,sudden in onset,non progressive no aggravating and relieving factors 

No c/o blurring of vision 

No c/o involuntary movements

No c/o SOB, palpitations,chest pain,orthopnea,PND 

No c/o fever ,vomitings,loose stools 

No c/o decreased urine output,pedal edema 

PAST HISTORY :

N/K/C/O HTN,DM,BA, Epilepsy,CVA,CAD 

No similar complaints in the past 

PERSONAL HISTORY: 

Diet : mixed 

Appetite: normal 

Sleep:Adequate 

Bowel and bladder movements:regular 

No addictions 

GENERAL EXAMINATION: 

Patient is conscious,coherent, cooperative and well oriented to time ,place ,person 

No signs of pallor,icterus,cyanosis,clubbing,lymphadenopathy, generalized edema . 

VITALS: 

Temperature:Afebrile 

BP: 130/90 mm hg 

PR: 86 BPM 

RR:16 cpm 

Spo2:93% at RA 

GRBS:146mg/dl 

SYSTEMIC EXAMINATION : 

CVS :S1 S2 Heard,no murmurs 

RS: BAE present , NVBS heard 

Per abdomen: Soft,non tender, no organomegaly 

CNS : 

                              Right              Left 

 Tone-UL            HYPER       HYPER 

           LL           Normal.    HYPER 

Power-UL          4/5               0/5 

             LL           4/5               0/5 

            BICEPS       +3              +3 

         TRICEPS       +1              +2

     SUPINATOR    +1              +1

       KNEE             +1                +2

      ANKLE             +2              +1

PLANTAR.       EXTENSOR     EXTENSOR 

COURSE IN THE HOSPITAL FORMATA 

65YR OLD FEMALE ADMITTED WITH C/O GIDDINESS FOLLOWED BY FALL ON 23-09-23. NECESSARY INVESTIGATIONS WERE DONE AND DIAGNOSED WITH CEREBROVASCULAR ACCIDENT WITH LEFT HEMIPLEGIA WITH DYSARTHRIA SECONDARY TO INFART IN RIGHT CEREBELLAR HEMISPHERE AND CONSERVATIVELY MANAGED AND SYMPTOMS SUBSIDED PATIENT IS HEMODYNAMICALLY STABLE AND PLANNED FOR DISCHARGE

PULMONOLOGY REFERAL DONE ON 30-09-23 I/V/O LEFT LOWER LUNG CONSOLIDATORY CHANGES

RESPIRATORY SYSTEM EXAMINATION :

BAE,VBS DECREASED INTENSITY OF BREATHE SOUNDS IN B/L IAA, ISA

FINE CREPTS+  LEFT ISA AND INFRA SA

ULTRASOUND IMPRESSION 25-09-23

IMPRESSION RIGHT RENAL CORTICAL CYST BA RAISED ECHOGENECITY OF KIDNEYS 

USG CHEST DONE ON 30-09-23

IMPRESSION : CONSOLIDATORY CHANGES IN THE LEFT LOWER LUNG FIELD

2D ECHO

Investigation 

HB : 12.2 gm/dl 

PLATELETS:  2.41 LAKHS CUMM

TLC: 1700CELLS CUMM 

CUE : 

ALBUMIN : NIL 

SUGARS: NIL 

PUS CELLS :2-3 

RFT: