A 46 yr old man presented with complaint of difficulty in walking

Hi, I am  princy rose , 5 th sem medical student.This is an online elog book to discuss our patients health data after taking his consent.This also reflects my patient centered online learning portfolio.


June 1 ,2023

Case scenario.......



CASE SHEET:


A 46yr old patient , mechanic by profession presented to the casualty with complaints of difficulty in walking 

CHIEF COMPLAINTS 


➤Deviation of mouth to right side since Saturday night 

➤Weakness of left upper and lower limbs since Sunday morning 


HISTORY OF PRESENTING ILLNESS


Patient was apparently asymptomatic 6 days back . 

Then suddenly he developed deviation in his mouth to the right side on Saturday night . 

While coming back from the washroom on Sunday he suddenly developed weakness in his legs due to which he sat down . He visited a local hospital and was diagnosed with hypertension, for which he was given medication but the symptoms didn't subside and the weakness progressed and he's unable to walk . 

No slurring of speech and drooling of saliva. 


HISTORY OF PAST ILLNESS


➤Not a K/c/o hypertension, asthma , epilepsy tuberculosis , CAD

➤k/c/o diabetes for 10 yrs 

➤No surgical history

➤No history of Blood transfusions.


DRUG HISTORY 


Tab. Glimestar M2 for Diabetes

 for last 10yrs 


PERSONAL HISTORY


➤Occupation: Skilled worker (mechanic)

➤Patient is married 

➤Patient takes mixed diet and has a normal appetite.

➤Bowel and bladder movements are normal 

➤No known allergies 

➤Addictions - Consumes alcohol every evening (180ml/day)

Consumes tobacco (10-15 times/day) 


Family History 


Mother is a k/c/o hypertension and diabetes 

Brother is a k/c/o hypotension and diabetes 


General Examination


➤Pallor : not seen 

➤Icterus : not seen 

➤Cyanosis : not seen 

➤Clubbing : not seen 

➤Lymphadenopathy : not seen

➤Edema : not seen 

VITALS 


➤Temperature : 100℉

➤PR : 108beats per minute

➤BP : 120/82 mm of Hg

➤RR : 20 cycles per minute

➤SpO2 : 98% in room air

➤Blood Sugar (random) : 204mg/dl


SYSTEMIC EXAMINATION


CARDIOVASCULAR SYSTEM EXAMINATION


➤s1 and s2 heard

➤Thrills absent

➤No cardiac murmurs


RESPIRATORY SYSTEM


➤Normal vesicular breath sounds heard.

➤Bilateral air entry present

➤Trachea is in midline.


ABDOMINAL EXAMINATION


INSPECTION

➤Shape - Scaphoid

➤Equal movements in all the quadrants.

➤No visible pulsation, dilated veins and localized swellings.

PALPATION

➤Liver , spleen not palpable

➤No tenderness  


CENTRAL NERVOUS SYSTEM EXAMINATION 


➤Conscious and coherent

➤Speech : Normal

➤No signs of meningeal irritation 

Neck stiffness: no 

Kernig's sign : no 



PROVISIONAL DIAGNOSIS : LEFT HEMIPLEGIA SECONDARY TO ACUTE CVA IN RIGHT MCA TERRITORY




INVESTIGATIONS


1) USG 






2) ECG







3) 2D ECHO 






4) MRI 








TREATMENT


1. Inj. Thiamine - 400mg in 100ml NS IV/stat 


2. Inj. Thiamine - 200mg in 100ml NS IV BD


3. Inj. Haz s/c 


4. Tab. Ecospirin 


5. Tab. Amlodipine -5mg


6. Tab. Dolo 


7. Physiotherapy 



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