60 year old male with acute infarct in brain

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 problems with collective current best evidence based inputs. 

Unit 1 case:

UNIT 1 ADMISSION


A 60 yr old male , labourer by occupation having 4 children  resident of kattangur, presented to casulaity with c/o 

--left upper limb, lower limb  weakness since today evening which was sudden onset 

--C/o giddiness since today evening

HOPI:

--Patient used to do his regular activities and  has does his routine work since today evening , patient had an episode of sweating , giddiness and left ul, ll weakness  which was sudden onset 

--Patient was unable to stand or walk with support

--Patient was taken to local rmp where they told his bp was high  so they refer patient   to our hospital

--Patient is conscious and confused on admission

Past history:

--K/c/o hypertension since 3 yrs - on regular medication, didnt use medication since 3 days

--Not a k/c/o diabetes mellitus, asthma, cad, tb, cva, epilepsy

Personal history:

Diet- mixed 

Appetite - normal

Sleep- adequate

B&B - normal, regular

Occassional alcoholic, non smoker

General examination:
Pt is conscious and confused 
Moderately built and nourished

Vitals:
Afebrile
Bp- 160/90 mmhg
Pr- 68bpm
Rr-20cpm
Spo2- 98% on room air
Grbs-116%
 
Pallor+

Icterus, cyanosis, clubbing, lymphedenopathy ,  edema are not present

Systemic examination:

CVS: s1, s2 heard

Rs- BAE+ NVBS+

P/A : soft, non tender

CNS:
conscious, confused
Normal speech
Power- R        L
    UL    5/5     4/5
    LL     5/5     4/5
Hand   100%  20%
Grip

Tone
UL         N           N
LL   increased  increased
Reflexes
Biceps    2+       2+
Triceps   2+       2+
Knee       2+      2+
Ankle      -          -
Babinski sign- negative



INVESTIGATIONS:

MRI:

2D echo:


Chest x Ray:

ECG:
Hemogram:
Hb- 13.1
Tlc- 84,00
PLT- 2.04
RBC- 4.43

LFT:
Tb- 0.85
Db-0.20
Ast- 16
Alt- 10
Alp- 190
Tp- 6.3
Alb- 4.1
A/g- 1.99

RBS- 95

RFT:
Urea- 21
Creatinine- 1
Na+ 143
K+ 4.1
Cl- 104


Provisional diagnosis:
Left hemiparesis ?cva( acute ischemic stroke)
? Right mca territory



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