A 59 year old male came with upper and lower weakness since 1 day

 February 20, 2023

This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box are welcome. 

Name:Manvitha (intern)

Chief complaints:

Right upper and lower weakness since 1 day

HOPI:

Patient was apparently asymptomatic till 1am of 19/2/2023 while watching TV he developed of weakness of right upper and lower limb and had H/O fall of remote from his hand with deviation of mouth to right side and slurring of speech 

The weakness lasted for atleast 2-3 seconds and recovered after massage of right upper and lower limb

Then after 15min similar episode occurre again and he was shifted to nearby hospital where they suggested to nearby hospital by his attender 

There is no H/O of LOC, Vomitings, fever

No involuntary passage of urine, no uprolling of eyes no tounge bite, no involuntary movements of limbs, no headache, no frothing through mouth , weakness not progressed 

No fresh episode in the past 

No similar episodes in the last 

Past history 

K/C/O DM 2 since 4 months on medication T. Metformin(500mg)+ T Glimiperide (1mg)

HTN diagnosed yester During the episode 

Personal history 

Diet mixed 

Appetite decreased relieved on medication

Sleep adequate

Bowel and bladder regular 

No known allergies

Habits:regularly takes  alcohol 90ml/day stopped 1 month back

Family history: no significant family history 

General examination:

Patien is conscious coherent cooperative 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema 


Vitals:

PR:65bpm

BP: 200/80 mmHg

RR:46 cpm

Spo2:98%

GRBS:238mg/dl

CVS examination:

S1,S2 heard

No additional sounds heard

RS examination:  position of trachea central 

BAE +, NVBS +

Per abdomen:

Swelling seen over the umbilicus 

Soft in consistency 

Site at umbilicus area

Size 4X5 cm 

Shape circular 

Surface smooth 

Skin over the swelling normal 

Surrounding area normal 

Shape of abdomen obese 

No tenderness

No palpable mass

No organomegaly 


Clinical images 













Investigations:



ECG













USG 
No sonological abnormality 

Chest X ray



MRI 
Acute infarct in left corona radiata & left basal ganglia.

Provisional diagnosis 

Acute Ischemic stroke with left putaminal infraction 

Treatment 

TAB ECOSPRIN AV/75/10/PO/HS
TAB GLIMIPERIDE + METFORMIN 500mg PO/OD
TAB NOCARDIA 10mg/PO If BP greater than 180/100mmhg
MONITOR BP, PR,RR, SPO2







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