65 yr old man with Right sided weakness & slurred speech

 I am Soumya 5th semester student .

This is an e-LOG depicting patient's de-identified data centered approach for learning medicine. This log has been created after taking consent from  patient and his family. Here we discuss about patient's problems with a series of inputs with an aim to solve them

CHEIF COMPLAINTS

A 65 year old man K/c/o DM since 5 years presented to causility with complaints of right sided weakness and slurred speech 

HISTORY OF PRESENT ILLNESS
Apparently normal 5 years back ,then he had complaints of fever ,pedal edema (pitting type) and polyuria went to hospital and found to have typhoid,investigation revealed deranged RFT diagnosed Kidney disease and had undergone dialysis for 2 times
Also found to have Diabetes 
Then had fistula operation on hand
Had dialysis for 2 years
Since 3 years he was alright without dialysis 
30 days back he had history of trauma to his right leg with farming equipment for which he had dressing by local RMP
3 days back he had tingling sensation in right Upper limb and day before had 
Clicking sensation in right foot , slipped And fell down and got up and went in home and sat on chair then he was unable to get up from chair and had right sided weakness and slurred speech ,BP was 220 when checked by local RMP and given antihypertensive.

HISTORY OF PAST ILLNESS

K/c/o DM since 5 years 

TREATMENT HISTORY

  K/c/o DM since 5 years and took insulin 4 units once daily few days 

FAMILY HISTORY
 No significant family history 


PERSONAL HISTORY

Mixed diet
Appetite normal
Bowel movements regular
Micturition normal
No known allergies 
Alcohol: occasional
Smoking Bidi 
Daily routine 

GENERAL EXAMINATION

  • O/E
  • Pallor: absent
  • Icterus: absent
  • Cyanosis: absent
  • Clubbing of fingers:absent
  • Lymphadenopathy: absent
  • Oedema of feet: present 
      Vitals:
  • PR : 66 bpm
  • Temp :98.8 F
  • RR : 18 cpm
  • BP : 130/70 mmHg
  • Spo2 : 98% at room air
  • GRBS : 131 

SYSTEMIC EXAMINATION
 CVS: 
    Thrills:No
    Cardiac sounds:S1 ,S2 present 
    Murmurs : absent 
 RS:
    Dyspnea:No
    Wheeze:No
    Position of trachea:cental
    Breath sounds: vesicular 
 Abdomen
    Shape of abdomen: scaphoid
    Tenderness:No
    Palpable mass:no
    Hernia orifices:normal
    Free fluid:no
    Bruits:no
    Liver :not palpable 
    Spleen :not palpable 
    Bowel sounds :Present 
 CNS :
  • HMF - Intact 
  • Concious
  • Speech: slurred 

  • Motor-                Rt.                      Lt
  1. Tone.    UL         Decreased        N
                  LL.       Decreased       N

      2. Power.   
                      UL.            0/5.               4/5
                
                      LL   .         4/5               4/5

                   

       3. Reflexes 
                     
                 Biceps              -                  +2

                 Triceps            +2                +2

                 Supinator        +1               +1

                 Knee                  +2              +2   

                 Ankle                 -                    -

                 Plantar              E                  E


PROVISINAL DIAGNOSIS


    Acute Ischemic stroke 

INVESTIGATIONS

5/8/22












6/8/22






7/8/22







8/8/22


9/8/22






10/8/22




DIAGNOSIS:

Acute ischemic stroke with RT hemiparesis 
Rt.Thalamus Lt.lentiform 
?? Emboli from AV fistula
K/c/o DM since 5 years and CKD

TREATMENT PLAN

5/8/22

  • Pt - c/c/c
  • PR - 60 bpm
  • BP - 10/80 mmHg
  • RR - 18 / min
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard           
Rx.
1.T.ECOSPIRIN 150 mg stat
      75 mg OD
2. T.CLOPITAB 75 mg stat
      75 mg OD
3.T. ATORVAS 80 mg stat
       ATORVAS  40 mg OD
4.Inj. OPTINEURON 1 amp +100 ml NS/IV/OD
5.Inj.HAI SC  a/c GRBS

6/8/22 
  • Pt - c/c/c
  • PR - 76 bpm
  • BP - 180/100 mmHg
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard   
  • CNS      HMF - Intact 

    • Motor-                Rt.                      Lt
    1. Tone.    UL        Decreased        N
                           LL.       Decreased       N

          2. Power.   
                          UL.            0/5.               4/5
                    
                         LL   .         1/5               4/5
  • Reflexes 
  •                      
  •              Biceps.             -          +2
                 Triceps                +2           +2

                 Supinator.             +1        +1

                 Knee                    +2           +2   

                 Ankle                    -               -

                 Plantar                 E               

Rx.
1.T.ECOSPIRIN 75 mg OD/PO
2. T.CLOPITAB  75 mg OD/PO
3.T. ATORVAS 10 mg PO/OD
4.Inj. OPTINEURON 1 amp +100 ml NS/IV/OD
5.Inj.HAI SC  a/c GRBS
6.T.Nodosis 500mg/po/BD
7.T.SHELCAL 500 mg/PO/OD

7/8/22

Acute ischemic stroke with RT hemiparesis 
Rt.Thalamus Lt.lentiform 
?? Emboli from AV fistula
K/c/o DM since 5 years and CKD
  • Pt - c/c/c
  • PR - 90 bpm
  • BP - 140/70 mmHg
  • RS -  Bilateral air entry present and clear
  • CVS - S1 & S2 are heard
  • GRBS 174 mg/dl    
  • CNS      HMF intact
    • Motor-                Rt.                      Lt
    1. Tone.    UL        Decreased        N
                      LL.       Decreased       N  
Input/output - 700/750
Rx.
1.T.ECOSPIRIN 75 mg OD/PO
2. T.CLOPITAB  75 mg OD/PO
3.T. ATORVAS 10 mg PO/OD
4.Inj. OPTINEURON1 amp +100 mlNS/IV/OD
5.Inj.HAI SC  a/c GRBS
6. T.Nodosis 500 mg/PO/BD
8/8/22 
  Physiotherapy - streching exercise  
Improved movement seen



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