DISCHARGE SUMMARY

DEPARTMENT OF NEUROLOGY
POSTGRADUATE INSTITUTE OF MEDICAL EDUCATION AND RESEARCH
CHANDIGARH – 160012
NAME SATISH CHANDER AGE 61 SEX MALE

FATHER’S ADMISSION
R K CHAND CR NO 202202115011 2022025074
NAME NO.

ADDRESS NORTH BLOCK, NEW DELHI CONTACT NO. 8920914088

PROF V LAL
DOA 16/04/22 DOD CONSULTANT
Dr. RITU

Acute ischemic stroke

Rt MCA infarct
DIAGNOSIS
Hypertension
CKD (not on HD )

Chief complaints:
Acute onset weakness of left upper limb and left lower limb with dysarthria on 15/4/22

HOPI :
61 year old male, k/c/o HTN and deranged RFT since 2016 presented with acute onset weakness of left upper limb
and left lower limb since 11am on 15/4/22 with deviation of angle of mouth to the right and slurring of speech. No
h/o sensory disturbance. H/o urinary incontinence two episodes with no sensation of passing urine. No h/o other
cranial nerve involvement. No h/o cerebellar dysfunction. No h/o tonic clonic movements. No h/o fever, headache,
neck rigidity.

Past History:
k/c/o HTN x 5 years
k/c/o CKD x 5 years (Last S. creatinine 2.3)
Personal history:
Sleep normal
Normal bowel
Vegetarian diet
Non alcoholic, non smoker
Family history : No significant family history.
GENERAL PHYSICAL EXAMINATION ON ADMISSION:
E4V5M6
NIHSS –13 on admission , NIHSS at discharge 13
Vitals:
Pulse: 84/min
BP: 140/90 mmHg
RR: 14 bpm; SpO2: 98% @RA
No Pallor /Icterus/lymphadenopathy/cyanosis /clubbing/peripheral edema

SYSTEMIC EXAMINATION
CVS: S1, S2 normal. No added sounds
RS: B/L air entry equal. B/L vesicular breath sounds. No added sounds
P/A: Soft, Distended
Bowel sound present
CNS: Responsive, obeying commands
Cranial nerves:
Right Left
I Normal Normal
II:
VF Normal Normal
Fundus Normal Normal
III, IV, VI Normal EOM
V Normal Normal
VII Normal Left UMN paresis
VIII,IX,X,XI,XII Normal Normal

Motor system:
Bulk : Normal
Tone : Increased in all four limbs.
Power:
POWER RIGHT LEFT
Shoulder:
Flexion 5/5 0/5
Extension 5/5 0/5
Abduction 5/5 0/5
Adduction 5/5 0/5
Elbow:
Flexion 5/5 0/5
Extension 5/5 0/5
Wrist :
Flexion 5/5 0/5
Extension 5/5 0/5
Hip :
Flexion 5/5 0/5
Extension 5/5 0/5
Adduction 5/5 0/5
Abduction 5/5 0/5
Knee:
Flexion 5/5 0/5
Extension 5/5 0/5
Ankle:
Planterflexion 5/5 0/5
Dorsiflexion 5/5 0/5

Reflexes B T S K A
Rt 3+ 3+ 3+ 3+ 2+
Lt 3+ 3+ 3+ 3+ 2+
Planters : B/L Flexor
Sensory examination: Normal
Cerebellar signs : Normal

INVESTIGATIONS
Investigation 17/4/22 19/4/22
Hmg 14.5/11300/215k 13.8/10800/173k
SE 141/4.61/108 141/4.64/105
RFT 69/2.40 67/2.31
Bil 0.89/0.14 0.74/0.30
Prot/Alb 7.9/4.27 7.11/4.19
Ca/P/Mg 9.3/4.3/2.6
OT/PT/ALP 55/38 31/27/92
CHOL/TG/LDL/HDL 155/87/34.5/163
TSH/T3/T4 3.67/8.27/0.73
HBA1C 6.3%
S.Iron/TIBC/%sat/ 54.6/311/17.56/60.02
Ferritin
PTH 86.8
Vit D 76.3

Urine r/e : Normal

Blood c/s (18/4/22) : Sterile
USG ABDOMEN
Chronic liver parenchymal disease
B/L renal parenchymal disease
MRI BRAIN + MRA (16/4/22)
Acute infarct in the right basal ganglia and periventricular region.
Confluent and discrete T2/Flair hyperintensities with few microhemorrhages in bilateral cerebral hemisphere f/s/o
chronic hyperintense encephalopathy.
Left otomastoiditis.
COURSE AND MANAGEMENT:
61 year old male wwith h/o hypertension on irregular treatment , has presented with h/o acute onset weakness of left
upper limb and lower limb along with left UMN facial palsy , and on examination he had complete hemiplegia with
NIHSS score of 13 at initial admission and mRs of 5, he was evaluated with MRI brain and has acute infarct in the
right gangliocapsular region and periventricular area and no major vessel occlusion and other work up with HBA1C ,
TFT , fasting lipid profile and 2d echo were done , started on dual antiplatelets and statins and limb physiotherapy and
he is being discharged with following advice

ADVICE ON DISCHARGE:
T. ECOSPRIN 150MG OD
T. CLOPIVAS 75MG OD
T. ATORVAS 40MG OD
T. AMLONG 5MG OD
T. ESCITELOPRAM 5MG OD
T. PREGAB NT HS
DVT prophylaxis as suggested

Follow up in Neurology OPD (Mon/Wed/Fri) after 1 month with FBS,PPBS, CBC, RFT
Follow up in ENT OPD

Dr. Nitish Dr. Sandeep Dr. Manod Prof V Lal/ Dr. Ritu
BED JR Bed SR WARD SR CONSULTANT