Chua/69/Chinese

NKDA
NON SMOKER/NON ALCOHOLIC

U/L
1) H/O CVA 3years ago – on T. Aspirin 75mg OD Admit at H. Columbia
2) HPT & DYslipidemia – compliance to medication

P/w

1) B/L LL weakness x1/7

- Fall backward
- No LOC/Vomiting
- Minimal bleeding at back of head

No unilateral weakness/numbness
No loose stool/fever
Oral intake as ususal
No abd pain
No giddiness/dizziness
No urti symptoms

Claim underwent acupuncture and traditional therapy

IN ed
BP 142/82
Hr 69
T 37
Spo2 97 RA
Reflo 7
Lungs Clear
No cerebellar sign, no nystagmus
Neurological exam intact
+ slurry speech
+ abrasion wound over R temporal region
Gag reflex present

Twc 5.04/hb 14.2/ph 177

VBG ph 7.846/pco2 44.1/hco3 25.3/lac 1.56

ECG SR, no acute ischaemic change

CT brain: no ICB minimal cerebral atropy

RP 8.4/140/4.7/146
Ca 2.55/po40.87/ mg o.81
Trop I <0.01
CNS all normal power 5/5

IMP TIA

POM T. Perindopril 5mg OD

T. Cardiprin 100mg OD
T. Atorvastatin 20mg ON

IN ward
Alert, conscious, orientated to time,place, person
BP 126/69
Pr 71
T 37
Spo2 98%RA
Lungs clear
PA SNT
CVS S1S2

Plan fall precaution

Encourage orally as tolerated
T cardiprin 100mg OD
T atorvastatin 20mg ON
Trace formal CT report
Refer to OT and PT
Normal saline over Right temporal region

25/9/19
Alert, no chest pain, no headache, no sob, no neurological deficit

Power 5/5 all limbs

Abrasion wound no bleeding

Plan allow discharge

Discharge with No medication

Medication
T. Cardiprin 100mg OD
T Atorvastatin 20mg ON
T perindopril 4mg OD