Case 28 - 45 YEAR OLD WITH RIGHT HEMIPLEGIA

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 45 YEAR OLD MALE WAS BROUGHT WITH C/O RIGHT UPPER LIMB AND RIGHT LOWER LIMB WEAKNESS SINCE 2 HOURS (AT 1 AM, 23/12/21) WITH DEVIATION OF MOUTH TO LEFT, LOSS OF SPEECH (+)

HOPI:
PATIENT CAME WITH 
C/O RIGHT UPPER AND LOWER LIMB WEAKNESS, SUDDEN IN ONSET, NON PROGRESSIVE SINCE 2 HOURS
DEVIATION OF MOUTH TO LEFT SINCE 2 HOURS
LOSS OF SPEECH SINCE 2 HOURS
NO C/O SEIZURES, FEVER, ALTERED SENSORIUM, HEAD INJURY
N/K/C/O DM,HTN

O/E
No cyanosis , icterus, clubbing , lymphadenopathy.
Temperature - 97.5°F
PR - 92/ min
RR - 18cpm
BP - 150/90 mmhg
Spo2 - 99% at RA
Grbs - 128mg/dl

CVS :- S1 , S2 heard
RS - BAE present
P/A - soft and non tender
CNS -
PATIENT IS CONSCIOUS, OBEYING COMMANDS, 
UNABLE TO SPEAK 
TONE-
                        R                       L
UL:           DECREASED      NORMAL
LL:           DECREASED      NORMAL
POWER-
                         R                      L
UL:                  0/5                  5/5
LL:                   4/5                 5/5
RELEXES-
                         R                       L
BICEPS            3+                    2+
TRICEPS          2+                     -
SUPINATOR     -                        -
KNEE                3+                    3+
ANKLE             3+                      -
PLANTAR        EXTENSION   FLEXION 

CEREBRAL SIGNS-
FINGER-NOSE- COORDINATION: ABSENT 
KNEE- HEEL- COORDINATION: ABSENT 

PROVISIONAL DIAGNOSIS:
ACUTE INFRACT IN LEFT FRONTAL LOBE, LEFT INSULAR CORTEX
LEFT ICA OCCLUSION

INVESTIGATIONS:



TREATMENT :
1.TAB.ECOSPIRIN 150 MG PO/STAT
    TAB.CLOPITAB 150 MG PO/STAT
    TAB.ATORVAS 80 MG PO/STAT
2. TAB.ECOSPIRIN 150 MG PO/OD
3. TAB.CLOPITAB 75 MG PO/OD
4. TAB.ATORVAS 80 MG PO/ H/S
5. INJ.OPTINUERON 1AMP IN 100ML NS OD
6. BP/PR MONITORING 2nd HOURLY 
7. GRBS MONITORING 12th HOURLY 

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