MEDICAL
REPORT
S.A/ 47YEARS/FEMALE
DIAGNOSIS: LEFT TOTAL ANTERIOR CIRCULATORY STROKE
BACKGROUND HISTORY AND PRESENTATION:
The
above named patient [resented to our facility on account of referral from a peripheral
center with complains of right sided weakness, left sided facial deviation and
slurred speech all of 8 hrs prior to presentation.
She
was in her usual state of health when she noticed that she could not stand up
from the toilet seat when she noticed the above symptoms. There was no history
of loss of consciousness, no seizures, no loss of consciousness, vomiting or
visual disturbances. She is a known hypertensive patient who is not regular on
medications.
NEUROLOGY:
GCS
E: 4, V: global aphasia M: 5, right sided hypotonia , power 0/5 on the right,
absent right plantar reflex.
NEUROIMAGING: MRI done showed obliteration of sulci in the left MCA with insula ribbon sign, no midline shift, angio shows MCA stem cut off/filling defect.
Based
on this finding the above diagnosis was made and a neurologist was called to
review.
MANAGEMENT
PLAN:
·
Tabs aspirin 300mg daily for 2 weeks
·
Tabs rosuvarstatin 20mg nocte
·
NGT for feeding
·
Physiotherapy
·
Tabs xeralto 10mg daily
·
IV normal saline 1l 12hrly for 2 days
She
gradually stated swallowing food properly and was weaned off the NG TUBE.
However still aphasic but has improved remarkably. She is yet to commence speech
therapy.
Discharge medications/ instructions
·
Tabs Aspirin 75mg dly
·
Tabs rosuvarstatin 20mg nocte
·
Tab xeralto 10mg daily
·
Tabs amlodipine 10mg daily
·
Should contact HMO concerning
physiotherapy and speech therapy
·
To present to the hospital on 14th
of September by 2:00pm to be seen by neurologist.
Kindly
revert to us for further clarifications where necessary
Yours
Sincerely
Dr.
Oseni Somina
For
Team Wellington Clinics Abuja.