A CASE OF ACUTE ISCHEMIC STROKE
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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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 diagnosis and treatment plan.
A 70yr old male who is a tractor driver by occupation was brought to the casualty with a chief complaints of inability to lift his right upper limb and after 2 hrs he was unable to talk and identify his family members and unable to lift his right lower limb .
HOPI : patient was apparently alright yesterday and performing his regular activities , later he was unable to lift his right upper limb which was sudden in onset , later after about 2 hours he was unable to talk , identify his family members and lift his right lower limb.
H/O fever 7 days back which was low grade , intermittent and associated with chills. It was relieved by medication prescribed by a local doctor.
H/O cough with expectoration , which was voluminous , mucoid , non blood tinged and non foul smelling.
PAST HISTORY ::
There were no similar complaints in the past.
Denovo DM
No H/o HTN , asthma , epilepsy or tuberculosis.
No past surgical history.
PERSONAL HISTORY ::
Appetite Normal
Sleep adequate
Bowel and bladder regular
Chronic alcoholic since 30 years , consumes 90ml of whiskey daily .
No smoking and ghutka consumption.
FAMILY HISTORY ::
Not significant.
GENERAL EXAMINATION ::
Patient was brought to the casualty and his GCS is E4V1M5. He is conscious, not cooperative and not oriented to time , place , person .
No pallor , icterus, cyanosis, clubbing, lymphadenopathy and edema..
VITALS :
Temperature : afebrile
B.P : 110/70 mm Hg
Pulse rate : 82bpm
Respiratory rate : 16 cycles per min.
SpO2 : 92% on room air.
Systemic examination :
CNS : patient is conscious, not cooperative.
Speech : Aphasic
No meningeal signs
Cranial nerves : loss of nasolabial folds on right side and deviation of mouth to left side. Forehead wrinkles are normal suggesting UMN facial palsy.
Other cranial nerves are normal.
POWER : could not be assessed as patient is not cooperative.
TONE : hypotony of right upper and lower limbs
REFLEXES : right side. Left side.
B. Absent. Absent
T. Absent. Absent.
S. Absent. Absent.
K. Absent. 2+
A. Absent. Absent
Plantar reflex exaggerated on both sides.
CVS ::
S1 ,S2 heard , no murmurs.
Apex beat at left 5th intercostal space at mid clavicular line.
RESPIRATORY SYSTEM::
Position of trachea central
BAE Present
B/L infraclavicular expiratory wheeze
B/L inspiratory crepitations.
PER ABDOMEN::
Soft and non tender , bowel sounds +
CLINICAL IMAGES ::
