27year old with CVA

 


This is an 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 patient's clinical problems with collective current best evidence based inputs". This E log book also reflects my patient-centred online learning portfolio and your valuable comments on comment box is welcome. 


I've 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 treatment plan.

Name :- Naga Varsha 

Roll no:- 87


Case report  

27 yr old male presented to casuality with c/o giddiness 6hrs ago , 

Right UL and LL weakness since 6 hrs 

Deviation Of angle of Mouth to left 

Slurring of speech  since 6 hrs 


History of Presenting illness :- 

Patient is apparently asymptomatic 6hours ago while he was driving Tractor hehad 2 episodes of Giddiness following that he developed Right Upper And Lower Limb weakness, sudden in Onset ,Non Progressive,Unable to lift the hand Above the level of head. Deviation Of angle of mouth to Left side 

Slurring Of speech since 6 hrs.No H/O of Trauma, falls.No H/O Uprolling of Eyeball,involuntary Micturition, defecation 


Past History 

K/c/o Seizure Disorder since 20 yrs not on medication (Last Episode:- 10 yrs ago 

N/K/C/O DM,HTN, CAD,CVA,Asthma,TB, Epilepsy


Personal History 

Known alcoholic consumes Alcohol Daily - 180mL


No family History 


O/E 





Pt is C/C/C 

No pallor, icterus, cyanosis, Clubbing, Lymphadenopathy,pedal edema 

Temp:- 96.8F

PR:-122bpm

RR:-18 cpm

BP:- 200/140 mmHg

SPo2 :-98%on RA

GRBS:-104mg%

CVS :- S1s2+

RS:- NVBS

PA :- Soft NT 

CNS 

HMF- Intact 

No signs s/o Meningeal irritation 

Cranial Nerves:- Normal

Sensory System :- Decreased Fine touch in Right Side below Knee

Motor system :- 

                   RT            LT 

Tone  UL  hypo       normal

           LL   hypo       normal 

    

Power           RT            LT 

            UL    3/5           5/5

            LL    4/5            5/5


Reflexes     RT     LT

B                  -         1+

T                  -         -

S                  -         -

K                  -         1+

A                  -         -


Investigations 

CUE


Blood urea


Serum creatinine


Serum electrolytes


Hemogram




Treatment Given 

1.T. ECOSPIRIN PO STAT 

2.TAB.NICARDIA 10 MG PO STAT 

3.TAB. CLOPITAB PO STAT

4.TAB.ATORVAS PO STAT 

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