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60 Year Old Male- Acute Ischemic Stroke

 


 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-centered online learning portfolio and your valuable inputs on the comment box.


A 60 year old male patient, agriculture worker by profession, residents of Miryalguda, came to the OPD with chief complaints of: 


Chief Complaints:

Loss of Power in left upper limb since 1 month

Loss of power in left lower limb since 4 days 

Deviation of mouth towards right side since 4 days


History of Presenting Illness: 

Patient was apparently asymptomatic 1 month ago, then he developed loss of power in left upper limb, sudden in onset, gradually progressive from distal to progressive direction. 

Patient has used herbal medication for this. 

Later he developed loss of power in left lower limb, 4 days ago, sudden in onset, gradually progressive in character.

He also developed deviation of mouth towards right side, 4 days ago which was sudden in onset, gradually progressive in character.


Past History: 

History of loss of power in left upper limb , years ago which resolved after a couple of days. 

History of tuberculosis, 3 years ago, took ATT medications for 6 months. 

History of road traffic accident, 4 years ago, right wrist fracture and rod placed in right leg.

History of 2nd road traffic accident, 4 years ago, scapular fracture on the left side.

Patient was diagnosed with diabetes, used medications for a month then discontinued.


Not a known case of hypertension, coronary artery disease, epilepsy etc.



Personal History: 

 Mixed Diet (Veg, Non Veg) 

Normal Bowel and bladder movements 

Adequate sleep 

Normal Appetite 

Occasional Drinker (twice/month) 

Smoked 1 bid-hi/day till a year ago. 



Family History: 

No one has similar complaints. 



General Examination: 


Pulse Rate: 63/minute 

Respiratory Rate: 16/minute 

Blood Pressure: 100/60 mmhg

SP02: 98*c


Pallor: Absent 

Icterus: Absent 

Clubbing: Absent 

Cyanosis: Absent 

Lymphadenopathy: Absent 

Edema: Absent 



Systemic Examination: 

Cardiovascular System: 

S1 sound heard 

S2 sound heard 

No murmurs heard 


Respiratory System:  

Vesicular Breath Sounds Heard

Trachea Position Central 

No Dyspnoea 

No wheeze 


Abdomen: 

Shape of Abdomen: Scaphoid 

Tenderness: No

Palpable Mass: No

Hernial Orifices: Normal 

Free fluid: No 

Liver Palpable: No

Spleen Palpable: No

Bowel Sounds: Present 


Central Nervous System: 

Patient is conscious, coherent, co-operative 

Speech: Slurred



General Examination: 


Pulse Rate: 63/minute 

Respiratory Rate: 16/minute 

Blood Pressure: 100/60 mmhg

SP02: 98*c


Pallor: Absent 

Icterus: Absent 

Clubbing: Absent 

Cyanosis: Absent 

Lymphadenopathy: Absent 

Edema: Absent 



Systemic Examination: 

Cardiovascular System: 

S1 sound heard 

S2 sound heard 

No murmurs heard 


Respiratory System:  

Vesicular Breath Sounds Heard

Trachea Position Central 

No Dyspnoea 

No wheeze 


Abdomen: 

Shape of Abdomen: Scaphoid 

Tenderness: No

Palpable Mass: No

Hernial Orifices: Normal 

Free fluid: No 

Liver Palpable: No

Spleen Palpable: No

Bowel Sounds: Present 


Central Nervous System: 

Patient is conscious, coherent, co-operative 

Speech: Normal


Investigations: 

MRI Scan 



Provisional Diagnosis: 

Acute Ischemic Stroke


Treatment: 

Tab. Ecosprin 

Tab. MUT

















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