Case 27 - A 60 YEAR OLD MALE WITH ACUTE ISCHAEMIC 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

A 60 year old male,farmer by occupation came with complaints of:
  • Irrelevant talk since 10 days.
  • Altered sensorium since 10 days.
History of present illness:
Patient was apparently asymptomatic 10 days back then he developed altered sensorium and irrelevant talk.
No H/O limb weakness, seizures, headache, fever,vomitings/loose stools.

Patient was apparently normal and went to work on 12/12/21 and slept at night.On 13/12/21 after waking up the patient was walking aimlessly at home and was talking irrelevantly.

He was taken to outside hospital 2 days later and was diagnosed with acute infarct in right frontotemporoparietal region,was admitted and treated for the same.

C/O hallucinations present after admitting in the hospital. 

Past history:
H/O PTCA (2° to CAD) in 2016.
H/O giddiness 2 years ago diagnosed with CVA(left cerebellar infarct)-not on any medication. 
Denovo HTN.
Personal history:
Diet-mixed 
Appetite-normal
Sleep-adequate
Bowel and bladder movements-regular
Daily alcohol consumer-90-180ml 
Daily cigarette smoker-1 pack/day
General examination:
No pallor,icterus,cyanosis,clubbing,
lymphadenopathy,edema.
Vitals on admission:
Temperature-98 F
PR-93 bpm
RR-18 cpm
BP-190/110 mmhg
SpO2-98% @RA
GRBS-88 mg%
Systemic examination:
CVS-S1,S2 heard
RS-BAE present, NVBS heard
P/A-soft,non-tender
CNS
GCS-E4V3M6
Not obeying commands 
Irrelevant speech
Increased tone in all 4 limbs
Motor system-moving all 4 limbs
Reflexes:   Right        left
Biceps        3+             2+
Triceps      3+             2+
Supinator  3+            2+
Knee           3+            3+
Ankle         2+             2+
Plantar     mute       flexor
Investigations:
Provisional diagnosis:
Acute infarct in right frontotemporoparietal region.Denovo HTN.
S/P PTCA.
?Alcohol withdrawal delirium.
Treatment:
Tab.Ecospirin 150mg RT OD
Tab.Clobitab 75mg RT OD
Tab.Atorvas 40mg RT H/S
Tab.Telma 40mg RT OD
Tab.Met-xl 25mg RT OD
Tab.Librium 25mg RT BD
RT feeds 2nd hrly 100ml milk+water
Tab.Nicardia 10mg RT stat
Inj.Thiamine 100mg in 100ml NS IV BD
GRBS monitoring 12th hrly
BP/PR monitoring 2nd hrly

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