55M with acute cerebrovascular accident with acute infarct in left internal capsule with acute infarct in left occipital lobe with k/c/o hypertension since 1 year with k/c/o L lymphnode TB 15years ago

TEJASWINI MARISA(INTERN)

This is 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 problms 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 .

Chief complaints:
A 55 year old male came with c/o slurring of speech since 2 days
C/o deviation of mouth towards left side since 2 days
C/o headache left sided since 2days
Hopi:
Patient was apparently alright 2 days back then he had slurring of speech which is sudden in onset and deviation of mouth towards left side.
No weakness of upper and lower limb.
He is able to lift his hand, comb his hair, brush his teeth, able to wear his chappals, able to get up from bed
He is unable to get up from squatting position due to knee pains
No h/o involuntary movenents
No h/o of numbness or paresthesia
No LOC/ altered sensorium.
No h/o altered smell
No h/o blurring of vision
No drooling of sliva
No drooping of eyelids
No difficulty in swallowing
Past history:
K/c/o TB lymph node 15yrs back(ised medication for 6 months)
K/c/o HTN since 1 year on ATENOLOL and AMLODIPINE 5mg
He is not a k/c/o DM II,  CVA, CAD, ASTMHA
GENERAL EXAMINATION:
pt is c/c/c
No pallor, icterus, cyanosis, clubbing, generalised edema or lymphadenopathy
Vitals 
bp-130/80
Pr -90bpm
RR: 18
Spo2 -98% @ RA
Systemic examination:
Rs-bilateral air entry present 
      Nvbs 
CVS -s1 S2 heard
No murmurs 
CNS: HMF intact
Tone: R.        L
UL     N.        N
LL.     N.        N
POWER: R.        L
UL     5/5.        5/5
LL.     5/5.        5/5
REFLEXES: R.         L
biceps.      2+.        2+
Triceps.     2+.        2+
Supinator.   2+.       2+
Knee.          3+.         3+
Ankle.          2+.        2+
Plantar.   flexion.     Mute
Tongue Deviation towards right side
P/A:
Soft,non tender

Diagnosis - 
Acute CVA with acute infarct in internal capsule and left occiptal lobe
K/c/o HTN since 1 year
K/c/o L lymphnode TB 15years ago

INVESTIGATIONS:

CAROTID DOPPLER
MRI BRAIN
ECG


Xray chest
2D ECHO
USG ABDOMEN

DIAGNOSIS:
55M with acute cerebrovascular accident with acute infarct in left internal capsule with acute infarct in left occipital lobe with k/c/o hypertension since 1 year with k/c/o L lymphnode TB 15years ago


TREATMENT:
RT FEEDS 100ML MILK 4TH HRLY
                   200ML WATER 2ND HRLY
T. CLOPITAB 75mg RT/OD
T ECOSPRIN AV 75 RT/H/S
INJ OPTINEURON 1amp in 500ml NS IV/OD

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