Case presentation - SOAP Format - Stroke disease

1. RECURRENT CEREBRO-VASCULAR ACCIDENT
Patient Name: xxx DOA: 07/02/22
Age: 55 Y/O DOD: 11/02/22
Sex: Male
Chief Complaint (CC):
● Patient came with ℅ deviation of angle of mouth to right side since yesterday night.
● H/O slurring of speech × 1 week
● H/O difficulty in swallowing × 1 week
● H/O seizure 1 episode on 05/02/22 @7:30 PM
Past Medical History:
● K/C/O old CVA × 8 months
● K/C/O DM / HTN × 10 months On Treatment
Social History:
● Married
● No alcoholic, smoker, exercise
● Non - vegetarian
PHYSICAL EXAMINATION:
General Examination: Conscious, oriented, febrile.
Systemic Examination:
● CVS - S1S2 (+)
● RS - BAE (+)
VITAL SIGNS:
Vital/Date 7/02 8/02 9/02 10/02 11/02
Temp (F) 99° 98.6° 98.6° 98.6° 98.6°
Pulse/min 84 70 78 92 76
BP (mm/Hg) 130/90 130/80 130/80 140/90 130/80
Respiration 20 20 20 20 20
SPO2(%) 98 92 97 98 98
Laboratory Investigation:
Constituents Detected
Values
Normal Values Unit Status
Complete Blood Count
WBC:
Total WBC count 9.7 4.0-11.0 10^3 / μL Normal
● P/A - soft / BS (+)
● CNS – GCS: 11/15
● GRBS: 152 mg/dL

2. RECURRENT CEREBRO-VASCULAR ACCIDENT
Constituents Detected
Values
Normal Values Unit Status
Differential Count
Neutrophils % 75.9 50 – 80 % Normal
Lymphocytes% 13.7 25 – 50 % Low
Monocytes % 8 2 – 10 % Normal
Eosinophils % 2 0 – 5 % Normal
Basophils % 0.4 0 – 2 % Normal
Neutrophils # 7.3 2.0 - 8.0 10^3 / μL Normal
Lymphocytes # 1.3 1.0 - 5.0 10^3 / μL Normal
Monocytes # 0.8 0.1 - 1.0 10^3 / μL Normal
Eosinophils # 0.2 0.0 - 0.4 10^3 / μL Normal
Basophils # 0.0 0.0 - 0.2 10^3 / μL Normal
RBC
Total RBC 5.23 4 - 6.2 10^6 / μL Normal
Hemoglobin 13.3 11 - 18.8 g / dL Normal
Hematocrit (HCT) 41.0 35 – 55 % Normal
MCV 78.4 80 – 100 fL Low
MCH 25.4 26 – 34 pg Low
MCHC 32.4 31 – 35 g / dL Normal
RDW 14.2 10 – 20 % Normal
Platelet Count 269 155 – 400 10^3 / μL Normal
MPV 9.0 6 - 10 fL Normal
Department Of Biochemistry
Lipid Profile
Serum Cholesterol 114.6 < 200 mg / dL Normal
Serum TG 98.2 <150 mg / dL Normal
Serum HDL - C 32.5 >60 mg / dL Low
Serum LDL - C 60.4 <130 mg / dL Normal
Serum VLDL - C 19.6 < 30 mg / dL Normal
LDL / HDL ratio 1.9 1 - 3.5 % Normal
Total-C / HDL
ratio
3.5 1 – 5 % Normal

3. RECURRENT CEREBRO-VASCULAR ACCIDENT
Constituents Detected Values Normal Values Unit Status
Renal Function Test (RFT)
Blood urea 21 10 -40 mg / dL Normal
Creatinine 0.7 0.6 - 1.4 mg / dL Normal
Electrolytes
Sodium 132.6 135 – 145 mEq /L Low
Potassium 2.9 3.5 - 5.0 mEq / L Low
HbA¹C Test:
Glycosylated Hb (HbA1C): 7.6 % (Detected Value)
Interpretation:
ECHO Screening:
Report:
Carotid & Vertebral Doppler study:
● Thickened intima media complex of both carotid arteries.
● Bilateral carotid & vertebral artery flow pattern are within normal limits.
Cranial MRI:
● Patchy small acute & old infarct in left MCA territory region.
● Small old infarcts & multiple ischemic changes.
Screening of MR Angiography of Brain:
● Narrowing of M2 segment of left MCA with paucity of distal branches.
● Focal narrowing of M1 segment of right MCA with normal distal branches.
● Normal - 4 - 6 %
● Good diabetic control - 6 - 7 %
● Fair control - 7 - 8 %
● Poor control - > 8%
● Normal chambers
● No RWMA
● LVEF = 60 %
● Normal LV systolic function
● Values are normal
● Normal pericardium

4. RECURRENT CEREBRO-VASCULAR ACCIDENT
DIAGNOSIS:
● RECURRENT CVA
1. Right hemiparesis with focal Seizure
2. Left MCA infarct
3. Left MCA focal narrowing M2
● SYSTEMIC HTN
● DM -2
DRUG THERAPY
S.
No
Generic Name Dose ROA Freq. Day
1
Day
2
Day
3
Day
4
Day
5
1. Tab. Paracetamol 650 mg P/O Stat
✓ - - - -
2. Inj. Enoxaparin 0.6 ml S.C. BD
✓ ✓ ✓ ✓ ✓
3. Inj. Levetiracetam 500 mg IV BD
✓ ✓ ✓ ✓ ✓
4. Inj. Ranitidine 50 mg IV BD
✓ ✓ ✓ ✓ ✓
5. Inj. Aspirin 150 mg IV 0-1-0
✓ ✓ ✓ ✓ ✓
6. Tab. Clopidogrel 75 mg P/O 0-1-0
✓ ✓ ✓ ✓ ✓
7. Tab. Atorvastatin 40 mg P/O 0-0-1
✓ ✓ ✓ ✓ ✓
8. Tab. Amlodipine 5 mg P/O 1-0-1
✓ ✓ ✓ ✓ ✓
9. Syp. Cremaffin 5 ml P/O HS -
✓ ✓ ✓ ✓
10. Tab. Metformin 500 mg P/O 1-0-0
✓ ✓ ✓ ✓ ✓
PLAN ON DISCHARGE:
S. No Generic Name Dose ROA Freq. A/F /
B/F
Days
1. Tab. Levetiracetam 500 mg
P/O
1-0-1 A/F
For
5
Days
2. Tab. Aspirin 150 mg 0-1-0 A/F
3. Tab. Clopidogrel 75 mg 0-1-0 A/F
4. Tab. Atorvastatin 40 mg 0-0-1 A/F
5. Tab. Formin PG 1 516 mg 1-0-0 B/F
6. Tab. Rabelin 20 mg 1-0-0 B/F
7. Syp. Cremaffin 5 ml HS A/F