A CASE OF ACUTE CVA PRESENTED IN SUMMER 2023

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NOTE: 




  • The following E-log aims at discussing our patient de-identified health data shared after taking the guardian's signed consent. 



  • Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.



  • This E-log also reflects my patient's centered online learning portfolio.



I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom.


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

Date of Admission: 28/05/23


CHIEF COMPLAINTS 


➤Deviation of mouth to right side since Saturday night 

➤Weakness of left upper and lower limbs since Sunday morning H


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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