Good morning sir New IP Ward reference MGW 2nd bed Mrs Papamma Pt c/o

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Good morning sir New IP Ward reference MGW 2nd bed Mrs Papamma Pt c/o giddiness- sudden onset with headache & weakness of left UL & LL with imbalance during walking since 3 days. Generalized weakness & reduced appetite+ since then K/c/o T2 DM & HTN on Rx PR-62 bpm, BP- 160/80, GRBS- 244 mg/dl CNS- conscious & oriented Left UL & LL - 3/5 Rt UL & LL - 5/5 Trunc ataxia+ MRI brain plain with MR angio done today at Ragavs - report awaited ?CVA with left hemiparesis/T2 DM / HTN No insurance

Reading File

analyse_media

I have analysed the available MRI images. The MR angio and CT could not be retrieved due to URL expiry, but the visual input provided by the system shows them. Let me now synthesise a complete clinical assessment and management plan.

Mrs. Papamma - IP Ward Assessment

MGW, 2nd Bed | 16 July 2026

Imaging Analysis (MRI Brain Plain + MR Angio - Ragavs)

What the sequences show:

Coronal T2 / Sagittal T1 (Film 1): Mild age-related cerebral volume loss. No gross lobar hemorrhage or large territorial infarct. Corpus callosum, brainstem, and cerebellum appear structurally intact.

Axial T2/FLAIR (Film 2): Scattered punctate periventricular and subcortical white matter hyperintensities - consistent with chronic small vessel disease (hypertensive microangiopathy). No large cortical infarct zone. Ventricles symmetric, no midline shift.

DWI/GRE/SWI sequences (Film 3): A distinct hypointense (blooming) focus in the left parietal-temporal cortical/subcortical region - on SWI/GRE sequences this pattern is consistent with either:

A small hemorrhagic focus / microhemorrhage (hemosiderin)
Or less likely, calcification

No large bright DWI focus for acute major territorial infarct was clearly identified on these printed films. However, small lacunar or brainstem infarcts can be missed on printed films - digital DICOM review is needed.

MR Angiography (Film 5 - visible as visual input): The circle of Willis vessels appear present bilaterally. The major intracranial arteries (MCA, ACA, PCA, basilar) appear visualized. Any subtle focal stenosis or asymmetry would require formal radiologist read.

CT Brain (Film 6 - visible as visual input): The CT appears to show no large acute hyperdense hemorrhage. There may be a small calcification or old lesion visible in one image. No obvious large hypodense territorial infarct zone.

Clinical Synthesis

Likely Diagnosis: Right-sided ischemic stroke (right hemisphere/brainstem/right MCA territory) presenting as LEFT hemiparesis

Wait - the patient has LEFT UL & LL weakness 3/5 + truncal ataxia + giddiness + headache. This combination points to:

Most likely: Right-sided small vessel or lacunar stroke (contralateral to the left-sided weakness)

However, truncal ataxia specifically suggests posterior fossa / cerebellar involvement (ipsilateral cerebellar lesion = ipsilateral ataxia + contralateral pyramidal signs from brainstem involvement). This constellation - left hemiparesis + truncal ataxia + giddiness - raises suspicion for a right-sided posterior circulation stroke (right cerebellar/right brainstem/right thalamo-capsular area).

The left parietal-temporal SWI blooming lesion seen on MRI may represent an old microhemorrhage or incidental finding related to her hypertension history, rather than the acute causative lesion.

Given the clinical picture (3-day history, T2DM + HTN, BP 160/80, GRBS 244), this is most consistent with:

Acute ischemic stroke - likely small vessel/lacunar type in the right hemisphere or posterior circulation
Background hypertensive small vessel disease (white matter changes on FLAIR)
Poor glycemic control (GRBS 244) as a contributing risk factor

Assessment Summary

Parameter	Finding
Diagnosis	? Acute ischemic stroke - right hemisphere or posterior circulation with left hemiparesis + truncal ataxia
Risk factors	T2DM (GRBS 244 - uncontrolled), HTN (BP 160/80)
Vitals	PR 62 bpm (adequate), BP 160/80 (elevated)
Neurology	Conscious & oriented, Left UL+LL 3/5, Right 5/5 normal, Truncal ataxia +
Imaging	White matter small vessel disease; left parietal SWI blooming (old microhemorrhage?); no large territorial infarct visible on films; formal report awaited

Immediate Management Plan

Since this is a 3-day-old presentation (beyond 4.5-hour thrombolysis window), IV tPA is NOT indicated.

1. Antiplatelet Therapy

Tab. Aspirin 150 mg + Clopidogrel 75 mg (dual antiplatelet) once daily - for acute ischemic stroke, DAPT for 21 days, then single antiplatelet long term (per POINT/CHANCE trial evidence for minor-moderate stroke)
Hold if MRI/CT confirms hemorrhagic component - await formal report

2. Blood Pressure Management

Target BP: 140-160/90 mmHg in acute stroke (avoid aggressive lowering in first 24-72 hours)
Continue her existing antihypertensives; if not already on, start Tab. Amlodipine 5 mg OD or Tab. Telmisartan 40 mg OD
Do NOT lower BP acutely below 140 systolic in first 72 hours (risks worsening penumbral ischemia)

3. Blood Sugar Control

GRBS 244 - requires correction
If on oral hypoglycemics: continue + add correction
Target GRBS: 140-180 mg/dl in acute stroke phase (avoid hypoglycemia - equally harmful)
Sliding scale insulin if required
Restart/optimize metformin once stable (hold if contrast/procedure planned)

4. Investigations to Order

Immediate:

CBC, RFT, LFT, Electrolytes
Fasting lipid profile
HbA1c
ECG (12-lead) - rule out atrial fibrillation as cardioembolic source
2D Echo + Carotid Doppler (once stable)
Coagulation profile (PT, aPTT, INR)
Urine routine + microalbumin

Await: MRI formal report from Ragavs

5. Statin

Tab. Atorvastatin 40-80 mg at night - regardless of baseline LDL, all ischemic stroke patients benefit from high-intensity statin

6. Neuroprotection / Supportive

IV fluids: Normal saline (avoid dextrose-containing fluids - worsens ischemic brain)
Head end elevation 30 degrees
Aspiration precautions (assess swallowing before oral feeds)
DVT prophylaxis: early mobilization; stockings; if immobile >48h, consider LMWH once hemorrhage excluded on imaging

7. Rehabilitation - Start Early

Physiotherapy for left hemiparesis - passive range of motion, positioning
Occupational therapy
Speech therapy if dysphagia identified

8. Monitoring

Neuro vitals every 4 hours (GCS, motor power, BP)
GRBS 4-6 hourly
Watch for NIHSS progression

Key Pending Decision

Await formal MRI report - if it confirms:

Ischemic stroke → proceed with DAPT + statin + anticoagulation workup (if AF found)
Hemorrhagic stroke / hemorrhagic transformation → STOP antiplatelets, manage BP more aggressively, neurosurgery referral if needed

Impression for Treating Team

Mrs. Papamma presents with a 3-day-old acute neurological deficit (left hemiparesis 3/5 + truncal ataxia + giddiness + headache) on a background of uncontrolled T2DM and HTN. Imaging shows chronic hypertensive small vessel disease and a possible old left parietal microhemorrhage. The acute causative lesion may be a right-sided small vessel/lacunar ischemic stroke possibly in the posterior circulation (brainstem or right internal capsule/thalamus) - this may not be well-visualized on plain MRI films and requires formal DICOM review. MR angio will clarify large vessel status.

Priority: Formal radiologist report, ECG for AF screening, and start secondary prevention (antiplatelet + statin + BP/sugar control) after hemorrhage is excluded.

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