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Dr. Seetharaman presents a case of a 47-year-old male who experienced right upper limb heaviness, blurred vision, and left-sided headache in the morning. On examination, he had signs of a right-sided facial droop and weakness. MRI brain showed acute infarcts in the left thalamus, occipital regions, and cerebellar vermis, indicating a posterior cerebral artery territory stroke. He was diagnosed with a TIA/acute CVA and started on antiplatelet and anticoagulation therapy.
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Initials: J.S Age: 42 Sex: Male Race: African American
S.
CC:
“I am experiencing lower back pain that radiates to my left leg”
HPI
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Location: Lower back
Onset: 1 month
Character: Shooting and Stabbing
Associated signs and symptoms: nausea, vomiting, photophobia.
Timing: Sitting for extended periods, bending over and strenuous physical activity.
Exacerbating/ relieving factors: Tylenol and rest makes the pain tolerable, but not completely better.
Severity: 8/10 pain scale
Current Medications
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Metoprolol 100 mg tablet, PO once daily.
Acetaminophen 500 mg tabs, 1-2 PO q 6 hrs, PRN for pain. (not to exceed 3 g in 24 hr).
PMHx:
Diagnosis: Hypertension
Surgical Hx:
Laparotomy, 02/2000
Immunizations:
Childhood immunizations completed. Tetanus and Flu shots are up-to-date.
Soc Hx:
Unemployed. Lives alone and never married. Has one brother and both parents are alive. Performs physical exercise regularly at the gym, and uses seat belts all the time when driving. Denies tobacco and alcohol use.
Fam Hx
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ROS
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Skin: No rash or itching. No skin lesions or moles that are new or suspicious.
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Case Presentation .pptx
- 2. Patient details Name: Mr.Shanmugasundaram Age/Sex-47/male (Right handed) Weight- 60 kg Presenting date and time: 06/03/2023 ( 11:30 am)
- 3. Subjecti ve evidence Chief complaints: c/o right upper limb heaviness (feeling weak) F/B blurring of vision and left sided headache since morning around 6:30 am lasted for half hour then spontaneously recovered. H/O Presenting Illness: patient last seen normal around 4:30 am and doing his routine works in early morning after which he developed upper limb heaviness f/b blurring of vision and spontaneously recovered around 6:30 am . H/O persistent headache+
- 4. N/H/O vomiting,, slurring of speech, LOC, giddiness, seizure, fever, numbness, weakness of other limbs, Abnormal gait,drooling saliva. N/H/O chest pain, palpitation, syncope, shortness of breath, urinary and bowel disturbances. N/H/O similar complaints in past. Past history: No comorbidities
- 5. Allergic History: No allergic history known Social History & personal history: Diet – mixed sleep- regular Alcoholic(occasional) & smoker 3 cigars/day (3 pack years)
- 6. Objective evidence Vital signs: BP- 140/80 MMHG TEMP: 97.2 F HR- 94/MIN SPO2 – 98 % RA RR- 14/MIN CBG – 112 MG/DL All peripheral pulses are regular NO EVIDENCE OF PALLOR,CYNOSIS,ICTERUS,CLUBBING,LYMPHADENOPATHY,EDEMA.
- 7. Higher mental functions Appearance and behaviour – oriented to time,person & place Conscious – Gcs 15/15 ,B/L pupil 2 mm RTL Memory & attention – normal. Speech & language- able to tell one full sentence, difficulty in reading and writing
- 8. Cranial nerve –visual field intact Ext.ocular eye movements no restriction Corneal reflex – patient blink his eyes Taste intact,loss of nasolabial right side mouth deviation left side Gag reflex present Motor System – Bulk, tone UL/LL normal Both upper & lower limb right power 5/5 Sensory system : preserved Finger Nose Test, Rapid alternating movements, Heel-knee-shin – normal No Nystagmus. Reflexes: superficial and deep tendon reflexes – 2+ Plantar reflexes- extensors
- 9. CVS- S1 S2 heard RS- B/L Air Entry+ P/A – Soft, Non tender
- 11. Laboratory data: HEMOGLOBIN 14.5 UREA 18 CREATININE 0.8 SODIUM 140 POTASSIUM 4.5 CHLORIDE 103 CHOLESTEROL 212 ESR 06 HBA1C 5.9 PLATELET COUNT 154000 PT TEST 11.7 PT-CONTROL 11 INR 0.97 CHOLESTEROL 212 TRIGLYCERIDE 195 LDL/HDL 166/0.2 UREA/CREATININE 18/0.8
- 12. Diagnosis – TIA/ Acute CVA Compression neuropathy Radiculopathy
- 13. Radiographic data MRI BRAIN: Acute non hemorrhagic infarcts involving left thalamus, left medial and posterior occipital regions and cerebellar vermis- likely PCA territory Echo: No RWMA Normal lv systolic & diastolic function Trivial MR & TR/No PAH No Evidence of Clot or vegetation. USG Carotid Doppler: Increased intima media thickness in Left carotid No E/O hemodynamically significant stenosis in both carotid system.
- 15. Treatment: T.ECOSPRIN 150 MG stat f/b 75mg OD T.CLOPILET 75 MG OD T.Atorvas 40 mg HS INJ.CLEXANE 60MG IV OD.
- 16. PATHOPHYSIOLOGY OF STROKE Abrupt onset of focal neurological deficit that is attributable for a focal vascular cause TIA: A transient ischemic attack (TIA), also sometimes referred to as a “mini-stroke,” starts like a stroke but only lasts from several minutes up to 24 hours.
- 17. Dual antiplatelet therapy is recommen ded for an ABCD2 score of 4 or greater.