85-year old male patient

This is an online e logbook to discuss our patients de-identified health data shared after taking his/her/their guardian's signed informed consent.

Here we discuss our individual patient problems through a series of inputs from an available global online community of experts to solve those patients' clinical problems with collective current best evidence-based inputs.

Date of admission- 23/09/2021

A 85 year-old man, who is a farm worker by occupation, presented to the hospital with

- Weakness of left upperlimb and lowerlimb since 20 days

-Difficulty in swallowing since 20days 

-Deviation of mouth towards left side since 20 days

HISTORY OF PRESENT ILLNESS

Patient was apparently asymptomatic 20 days back, he had sudden onset of weakness of left upper limb and lower limb which was noticed by his attender, when he tried waking up from bed he couldnt get up and complained of weakness and was went to a near by RMP and was sent to our hospital for further management. 

No h/o trauma, no c/o giddiness, headache, chest pain, burning micturition, pedal edema. No c/o nausea, vomiting.

PAST HISTORY

- Known case of hypertension since 3 years 

- Not a known case of Diabetes mellitus, Asthma, Epilepsy

PERSONAL HISTORY

-Mixed diet of veg and non-veg food

-Appetite Inadequate

-Bowel movements- normal. No history of involuntary defecation

- Urine output- normal. No history of involuntary urination

-Patient is an alcoholic since 20 years

-Chronic smoker (4-5 chutta/day) since 20 years 

-Patient stopped smoking and drinking 2 months ago

TREATMENT HISTORY

-Patient is on antihypertensives since 3 years

GENERAL EXAMINATION

- Patient is conscious, coherent and cooperative

- Pallor- Yes

- Cyanosis- No

- Lymphadenopathy- No

- Clubbing of fingers- No

- Pedal edema- No

Temperature- Afebrile

Pulse rate- 100/ min

Blood pressure- 140/90 mmhg

Respiratory rate- 22 cycles per min

SPO2- 99 % at room air

CVS- S1 and S2 heard 

Respiratory system

NVBS present 

CNS 

Conscious 

Speech - normal

No signs of meningeal irritation

Tone- Increased in left side

Power- 

 Right. left

 4+/5. 4+/5

Reflexes-

Right. left

Biceps:. +. +++

Triceps:. +. +++

Gait         

Supinator:. +. +++

Knee : +. ++

Ankle:. +. +

Left extensor present (Babniski positive)

PROVISIONAL DIAGNOSIS

CVA with left UMN Palsy with acute infarct 

in Right Parietal lobe and Frontoparietal lobe

INVESTIGATIONS

ECG

MRI BRAIN

TREATMENT

RT FEEDS 100 ML MILK - 2ND HOURLY , 100ML HOURLY

2) INJ PAN 40 MG /IV/OD

3) INJ OPTINEURON 1 AMP IN 100 ML NS /IV/OVER 30 MIN

4)TAB ASPIRIN 100 MG RT/OD

5)TAB CLOPIDOGREL 75 MG RT /OD/H/S

6) TAB ATORVASTATIN 40 MG /RT/OD/HS