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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 


Patient was brought to casualty with complaints of deviation of mouth to left since yesterday morning,c/o slurring of speech since yesterday


HOPI: 

A 80Y/M who was a farmer by occupation (staying at home since 10-15Y) Patient was apparently asymptomatic 1 yr back. Patient c/o nocturia (10-12x) overnight and went to local hospital and diagnosed with DM-2  and since then he is on regular medication .Since yesterday patient woke  up from sleep. Patient complaints of deviation of mouth to left side and slurring of speech since yesterday.

Outside BP :190/100mmhg

No c/o involuntary micturition/defecation

No c/o involuntary movements

No c/o dysphagia 

No c/o UL/LL weakness noted

No c/o fever,cold,cough

No c/o  burning micturition since 1 month

No c/o sob, orthopnea


        


Past history:

k/c/o diabetes since 1 year and on regular medication since then

Not a k/c/o Htn/cad/Tb/bronchial asthma 

No past surgical history


Treat ment  history :On tab metformin 500 mg for diabetes since 1 year 


Personal history:

Married

Previously farmer

Appetite: Normal

BowelsBladder movements: Regular

 Addictions: 

Alcohol consumption (Occasional -90ml)

Had habit of smoking but stopped 5yrs ago

No other addictions


Family history : Not significant


o/e:

Pt is c/c/c ,well oriented to time,place, person.

Pallor +




No signs of icterus, clubbing, cyanosis, lymphadenopathy, pedal edema 



 Vitals: 

Temp: Afebrile

Pr: 62bpm

Rr:17cpm

Bp:160/90 mmhg

Spo2: 97% on ra

Grbs:129mg%


Systemic Examination:

Cvs:S1S2 heard, no murmurs heard

Rs: BAE+ ,NVBS heard

P/A: Soft, nontender







CNS:

pt conscious with Slurred speech

No signs of meningeal irritation 

                           left            right


1) Tone.   UL.   normal.     normal

                 LL.     normal    normal


2) Power    UL          5/5               5/5

                    LL           5/5             5/5


3) Hand grip.   100%


4)Reflexes

       a) Biceps.              +                   +

       b) Triceps             +                    + 

       c) Supinator.         +                    +

       d) Knee.                 +                  +                 

       e)Ankle.                 -                    -

        f) Plantar.           Mute         Mute


5)  Cerebral signs:

Finger nose coordination: -

Knee heel coordination: - 


Plan: 

1)tab ecosprin 75 mg po/od 

2)tab  atorvas 20 mg po/od 

3)inj optineuron 1 amp in 100 ml Ns IV/od 

4) physiotherapy 


Investigations:

Hemogaram:

Hb-11.1

Tlc-4,600

Pcv-31.9

Plt-1.81

Bgt- B positive 

Blood urea-30

Utica acid-4.4

Serum creatinine-1.2

Sodium-139

Potassium-3.5

Chloride-97

Tb -1.2

Db-0.4

Sgot-37

Sgpt-10

Alkaline phosphate-98

Tp -6.2

Albumin-4.0

A/G-1.86


chest x ray:





Carotid Doppler 



2D ECHO:-

Imp:-

-Trivial TR+ ; no MR/AR

-No RWMA/No MS/AS ; sclerotic AV

-Good LV systolic function

-Diastolic dysfunction + ; No PAH/PE


MRI brain 

Imp:-

-Acute Lacunar infarct in right corona radiata

-Old Lacunar infarcts in left thalamus and left corona radiata

-Chronic small vessel ischaemic changes



Diagnasis:

Acute  ischemic CVA with UMN type of left facial palsy with  acute infarct in right corona radiata 

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