A 68 year old male with slurring of speech and right side upper limb weakness

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

A 68 year old male who was a labour worker by occupation came to the casualty on 14/6/23 with the complaints of slurring of speech and right upper limb weakness since yesterday 

History of presenting illness:
Patient was apparently asymptomatic till yesterday morning then  he developed  slurring of speech around 10:30AM  and by afternoon 3:30 pm patient developed weakness of right upper limb.... then after sometime ( 3 to 4 hr) the weakness of right upper limb reduced .
No H/o fever, vomiting, diarrhoea 

Past history:

H/o giddiness since 1month ..... H/o fall 2 days back ( hypotension) taken to rmp 

Patient was diagnosed with hypertension 20 days ago and not on any medication 

Not a know case of DM, epilepsy, thyroid disorders 

Personal history: 
He has normal appetite, takes mixed diet, sleep is adequate, bowel and bladder movements are regular.


General examination:
Patient is conscious, coherent 
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema 





Vitals:

Afebrile to touch

Temp: 98.2°F

PR- 82 bpm

RR- 18cpm

BP- 160/90mmHg

SpO2- 96% 

Grbs - 118 mg%


Systemic examination 

CVS- S1 S2 present, no murmurs heard

RS-B/L air entry present, NVBS

PA- soft,non tender, bowel sounds heard

CNS -Pupils: B/L NSRL

Tone 

Power: Right upper limbs:     , Lower limbs:   

Left upper limbs:       , Lower limbs:  

Reflexes:

Biceps: Rt: +   Left: +++

Triceps: Rt: + Left: ++

Supinator: Rt: + Left: ++

Knee jerk: Rt: + Left: ++

Ankle: Rt: + Left: ++

Plantar: Rt: Extensor Left: Flexor


Investigations

On 14/6/23






Hb:  11  gm/dl

TLC:   8000 cells/ cumm

RBC:   4 million/cumm

PLT:   2.75 lakh/cumm

PCV: 33.4 vol%


Blood urea:  32  mg/dl

Serum creatinine: 1.6  mg/dl

Serum electrolytes: 

Na+:   138 mEq/l

K+:  3.6 mEq/l

Chloride :  103 mEq/l


On 16/6/23

Blood urea: 27 mg/dl

Serum creatinine: 1.3 mg/dl

Serum electrolytes: 

Na+: 142 mEq/l

K+: 3.9 mEq/l

Chloride : 102 mEq/l









Diagnosis:

ACUTE ISCHEMIC STROKE with  INFARCT IN B/L GANGLIOCAPSULAR AREA with CHRONIC INFARCT IN  RIGHT THALAMUS and LEFT BASAL GANGLION 

Treatment:




1.IVF NS AND RL @50 ml/hr

2.sips of oral fluids 

3.Tab. ECOSPIRIN  75 mg PO/OD 

4. ATORVASTATIN 40 mg PO/OD

5.physiotherpy of upper limb and lower limb 

6. Early mobilization

7. Monitor vitals inform sos 

8. Tab CINOD 10 mg PO/ SOS ( if bp is > 150 mm hg ) 






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