A 53- year -old women from komatpally, presented to hospital with:

Left side hemiplegia

Uncontrolled sugar from past 10 year

Renal mass noted in right upper pole of kidney

Headache from 2 days

Patient is suffering with chest pain


History of present illness:

-patient was apparently asymptomatic 10 yrs ago ,who was a agriculture worker.one week back ,patient was unconscious and partial paralysis on left side of the body.

patient is suffering with severe headache from past 2 days.patient is suffering with stomach pain at lower abdominal region.

patient is complaining with weekness from past 10 days.patient was referred to hospital and has been admitted here from past one week


Past history:

-No history of hypertension 

-Patient is suffering with diabetes mellitus  since 10 yrs

- patient is not suffering with asthma,epilepsy,tuberculosis 

-patient was never involved in any kind of accident 

-no past surgery


Personal history:

-mixed diet of veg &non - veg

-appetite is inadequate 

-patient is of ectomorphic built

- bowel movement- normal

-bladder movement-normal

- no habit of smoking and drinking


Family history:

No one in her family is suffering with similar problem of hemiplegia

Everyone in her family is suffering with diabetes mellitus


Allergy history:

-Patient is not allergy to any known drug or food

- they is no known allergy to dust or pollen


General examination:

Patient is non -coherent,conscious &dismissive

-patient seems fatique on examination 

- patient is suffering with anemia ,pallor 

-patient appears to be dehydrated.

Vitals:

Temp -afebrile

Pulse rate-92 bpm

Respiratory rate:17 cpm

Bp-110/70 mmHg

Systemic examination:

1.CVS:inspection-chest wall is bilaterally symmetrical 

             No visible pulsation .

           No visible scars .

2.Auscultation: S1 ,s2 , no murmurs

3.respiratory system-no added sound

         Position of trachea -central

           Bilateral air entry+

4. Per abdomen: abdomen is soft ,non -tender

                            Bowel sound is heard

5.CNS:

Patient is conscious 

Appearance and behaviour-thin built and dis oriented

Sensory system-non elicited

No. Meningeal signs  

INVESTIGATION:

-Hemogram 

-COMPLETE URINE EXAMINATION 


-SERUM CREATINE:


-LIVER FUNCTION


-GLYCATED HAEMOGLOBIN :


-BLOOD SUGAR:

-KETONE BODIES :


-HIV RAPID TEST:

 
-REPORT:

-ECG:

—USG abdomen 
         ? Kidney mass in right upper pole



PROVISIONAL DIGNOSIS:
          
       Cva with left side hemiplegia with uncontrolled sugar.

TREATMENT:
1- inj . Actrapid 60 iv /stat
2- inj -k6l 2 amp in 500 ml slow iv over 6 hours
3-RT feeds-200 ml milli 2nd hourly
4-tab ecospirin -75 mg /OD
5- tab atoroastatin -20 mg /OD












      

    



     












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