Hi, I am p.samhitha, 5th Sem Medical Student.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.

Hi, I am p.samhitha, 5th Sem Medical Student.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 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 a diagnosis and treatment plan.



Chief Complaint-

C/o weakness of left u/l and l/l since 2 days

C/o deviation of mouth towards right since 2 days



HISTORY OF PRESENTING ILLNESS-

Pt was apparently asymptomatic alright 2 days back. Then he had weakness of left UL and LL sudden in onset and deviation of mouth towards right since 2 days

Pt is unable to lift his hand above head 

No involuntary movements, no involuntary micturation/defecation

Able to swallow food , chew food 

No headache , No blurring of vision

No vomitings , no loose stools



PAST HISTORY-

N/K/C/O DM 2 , HTN , TB , Epilepsy, CVA ,CAD



PERSONAL HISTORY-

Diet - Mixed

Appetite - Normal

Bowel and Bladder movements- Regular

Sleep - Adequate 

Addictions - 150 ml alcohol daily

He is a labourer by occupation 



FAMILY HISTORY-

Not significant



GENRAL EXAMINATION-

Pt is c/c/c well oriented to time place and person 

No signs of pallor icterus cyanosis clubbing lymphadenopathy edema 



Temp - Afebrile

PR - 78 bpm

RR - 24 cpm

BP - 110/70 mmhg

Spo2 - 96 RA

GRBS - 119 mg%



CLINICAL PICTURES-
SYSTEMIC EXAMINATION-



CVS -

S1 S2 +

No thrills felt

No murmurs heard



RS -

B/l air entry +

Position of trachea central

No wheeze or rhonchi



P/A-

Shape - scphaoid

No tenderness or organomegaly present



CNS-

He is conscious 

Speech is slurred

No signs of meningeal irritation 

Motor System-

GCS 15/15 - E4V5M6
Power-

                           R. L. 

U/l 5/5. 1/5

L/l. 5/5. 1/5

Tone-

U/l. N. N

L/l. N. N

Reflexes-

B. 2+. 2+

T. 1+. 1+

K. 2+. 2+

A. 1+. 1+

Plantar Flexor. Extensor



PROVISIONAL DIAGNOSIS-

Acute CVA with Ischemic stroke in ? Rt MCA Territory with Left Hemiplegia



INVESTIGATIONS-

06/09/2023:

ECG -




Hb - 12.3 NCNC

Tlc - 7400

Plt- 1.2 lakhs/cumm

MCH - 36.1

MCV - 97.1

RBS - 90 mgdl

S. Urea - 22

S. Creat - 1

Na - 131

K - 3.9

Cl - 98

Ca - 1.1



MRI. -





Acute infarct in Right parietal cortex, right inferior temporal lobe, right caudate nucleus and right lentiform nucleus -right MCA territory infarets.

Few acute lacunar infarets in right parietal lobe.


MR angiogram sequences show stenosis of right ICA with non- visualization of right MCA.





Treatment Given-

IV Fluids NS @100 ml/hr

Inj Thiamine 200mg in 100 ml NS IV/BD

Tab Ecosprin AV 75/10 PO/HS

Inj Manitol 100 ml IV/OD

Physiotherapy 

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