NOTE: THIS IS AN ONLINE E LOGBOOK 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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT
A 50 YR OLD MALE, CARPENTER, RESIDENT OF VELIMINEDU, COMPLAINS OF WEAKNESS IN RT UPPER AND LOWER LIMBS SINCE 2 DAYS
PT WAS APPARENTLY ASYMPTOMATIC 2 DAYS AGO THEN AT NIGHT 11PM, HE HAD TREMORS AND WEAKNESS OF RT UPPER LIMB, WENT TO LOCAL HOSPITAL RMP, THERE BP WAS FOUND TO BE 180/140 MMHG AND WAS MANAGED WITH CINOD 10MG
AGAIN AT 2 AM, COMPLAINED OF WEAKNESS OF LEFT LOWER LIMB
HEADACHE IN LEFT PARIETAL REGION, PRICKING TYPE, SINCE 2 DAYS
VOMITINGS, 3 EPISODES, 2 DAYS AGO
NAUSEA +
SOB ON EXERTION SINCE 1 MONTH, ORTHOPNEA +
NO C/O CHEST PAIN, SWEATING, COUGH, GIDDINESS, BURNING MICTURATION, LOOSE STOOLS
K/C/O CVA WITH RIGHT HEMIPARESIS 2 YRS BACK
POWER IMPROVED ON T ECOSPRIN AV 75 MG OD
K/C/O SEIZURES 1 YR BACK, ON T LEVIPIL 500MG PO BD FOR 6 MONTHS AND STOPPED ON THEIR OWN. LAST SEIZURE 1 MONTH AGO
K/C/O HTN SINCE 6 YRS ON T TELMA H PO OD AT 8 AM, T CINOD 10MG AT 9PM AND T METXL 50MG AT 2PM
STOPPED ANTIPLATELETS 15 DAYS AGO AND SHIFTED TO HERBAL MEDICINE
PERSONAL HISTORY:
APPETITE NORMAL
DIET MIXED
BOWEL AND BLADDER MOVEMENTS NORMAL
SLEEP ADEQUATE
ALCOHOL( TODDY AND WHISKEY ) SINCE 5 TO 6 YRS, STOPPED 2 YRS AGO
FAMILY HISTORY:
BOTH PARENTS AND ELDER BROTHER ARE KNOWN CASE OF HTN
ELDER BROTHER HAD STROKE 10YRS AGO, EXPIRED AT 60Y OF AGE
GENERAL EXAMINATION:
EDEMA +
NO PALOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY
VITALS:
TEMPERATURE: 99.4F
PR: 68 BPM
BP: 140/90 MMHG
SPO2: 98% AT RA
RR: 20 CPM
GRBS: 109 MG/DL
SYSTEMIC EXAMINATION:
CVS: S1,S2 HEARD
RS: BAE +
P/A: SOFT, NON-TENDER
CNS:
ORIENTED TO TIME PLACE PERSON
TONE IN ALL 4 LIMBS NORMAL
POWER: RT UL 0/5, LT UL 4/5, RT LL 2/5, LT LL 4/5
REFLEXES ON RT SIDE:
B +++
T +++
S ++
K +++
A ++
P EXTENSOR
ON LT SIDE:
B ++
T ++
S ++
K ++
A ++
P FLEXOR
PUPILS REACTIVE TO LIGHT AND NORMAL IN SIZE
INVESTIGATIONS:
DIAGNOSIS:
RT HEMIPARESIS 2⁰ TO ACUTE INFARCT IN LEFT FRONTOPARIETAL TEMPORAL LOBE - MCA TERRITORY WITH LEFT FACIAL NERVE UMN PARALYSIS
K/C/O HTN SINCE 6 YRS AND CVA SINCE 1 YR
TREATMENT:
1. D2 INJ MONOCEF 1G IV BD
2. INJ LEVIPIL 500MG IV BD
3. T ECOSPRIN AV 75/10 PO HS
4. T PREGABA 75MG PO HS
5. T TELMA 40MG PO OD AT 8AM
6. T CLINIDIPINE 10MG PO BD
7.T NAXDOM 250MG PO SOS
8.2ND HRLY BP MONITORING
9.PHYSIOTHERAPY OF RT UL AND LL
10. LOOK FOR WORSENING SENSORIUM, GCS, SEIZURE EPISODE
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