7TH
March, 2023
MEDICAL
REPORT/DISCHARGE SUMMARY
F. A, 58YEARS, MALE
HOSP
NO: WCA/6062/2023
DIAGNOSIS: Right hemispheric ischemic
stroke with dyslipidemia
MANAGEMENT: Conservative management
Physiotherapy
DATE OF ADMISSION: 2/03/2023
DATE OF DISCHARGE: 07/03/2023
The
above named patient presented to our facility with sudden fall, sudden onset
left sided weakness and urinary incontinence of 14 hours prior to presentation.
Vitals
on admission BP: 170/100, RR: 18C/M, PR: 71B/M SpO2: 97%RA.
On
examination he had shallow but adequate mental higher function, attention
impaired, GCS 15/15, power in left upper limb was 4 and that of left lower limb
2, left hyporeflexia and hypotonia, and absent left planter reflex. Brain CT
done 2/03/2023 showed normal study. See image below
Investigations:
·
Rbs-5.3,
·
FLP- total cholesterol- 271.4,
triglyceride- 28.42, HDL: 4.72, LDL 260.9. values grossly deranged.
·
FBC, EUCR, LFT were within the normal
limit.
·
Carotid Doppler done was normal
·
ECG showed normal sinus rhythm.
He was reviewed by a cardiologist and
neurologist and the following management was carried out.
·
Tabs aspirin 300mg daily for 2 weeks
·
Tabs rosuvarstatin 20mg daily
·
IVF normal saline 1l 12hrly for 24 hrs
·
Physiotherapy
While
on admission, power in the left lower limb was noticed to have improved
remarkably to 5 in the left upper limb and 3 in the left lower limb. General
condition and remained stable since admission.
Discharge instructions/drugs:
·
Tabs aspirin 300mg daily for 1 week then
75mg daily
·
Tabs rosuvarstatin 20mg daily
·
To present for alternate day physiotherapy sessions for a week
·
Follow up visits on the 23/03/2023 by 3pm
Kindly revert for further
clarifications if need be.
Sincerely yours,
Dr.
Oseni Somina
For
Team Wellington Clinics
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