41year old male patient came to causality with c/o of tingling sensation of the right UL and right LL since 2days
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 patients 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 comment box is welcome
2D ECHO
USG abd
MRI Brain
Chest X ray
Provisional diagnosis:-
41year old male patient came to casuality with chief compliant of tingling sensation of the right upper limb and right lower limb since 2days ,c/o weakness of the right upper limb and right lower limb since 2days.
History of present illness:-
Patient was apparently asymptomatic 2days back then he developed tingling sensation of the right upper limb and right lower limb since 2days & history of decrease in strength, weakness of the right upper limb and right lower limb,No History of headache, vomitings etc.No history of sudden blurring of vision etc.
Past History:-k/c/o Hypertension since 3days & started on Tab.CINOD 10mg PO/OD
O/E
Pt was c/c/c
No pallor, icterus ,cyanosis,clubbing lymphadenopathy ,oedema
Temp:-afebrile
PR-98bpm
RR-22cpm
Bp-170/90mmhg
Spo2-98%
Grbs-141mg
CVS-s1s2 heard,no murmurs
Rs- BAE+,NVBS+
P/A- soft, non tender
CNS-
consciousness
Rt Lt
Tone UL reduced normal
LL reduced normal
Power UL 5/5 5/5
LL 5/5 5/5
Reflexes B ++ ++
T ++ ++
S ++ ++
K ++ ++
A ++ ++
P W E
Investigation:-
CVA WITH ACUTE ISCHEMIC STROKE WITH INFARCT IN THE LEFT THALAMUS WITH DENOVO DETECTED HTN
Treatment:-
1)TAB.ASPIRIN 150MG PO/OD
2)TAB.CLOPIDOGREL 75MG PO/OD
3)TAB.ATORVAS40MG PO/OD/H/S
4)TAB.PAN 40MG PO/OD
5) MONITOR BP 4TH HRLY
6)TAB.PREGABALIN 75MG /H/S
7)TAB.AMLONG 5MG PO/OD
8) INFORM SOS
