RECURRENT CEREBRO VASCULAR ACCIDENT ACUTE ISCHAEMIC STROKE
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Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input.
This E-blog also reflects my patient's centred online learning portfolio.
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 COMPLAINTS:
Patient complains of weakness in the Rt UL since 3 days associated with slurring of speech and shoulder weakness since 3 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 5 years back suddenly developed chest pain .Patient developed weakness in the B/L UL since 3 days Patient complains Of weakness in the Rt U/L unable to hold the glass ,eat food ,button and unbutton his clothes .
HISTORY OF PAST ILLNESS: Patient has history of B/L upper limb weakness 6 months back not associated with slurring of speech and used medication for 5 months
No history of hypertension ,Diabetes Tuberculosis, Asthma
PERSONAL HISTORY:
Married
Occupation : farmer
Appetite is normal
Bowel movements are regular
Bladder movements are regular
ADDICTIONS: patient is an occasional alcoholic since 40 years
Patient is a chronic smoker since 50 years
FAMILY HISTORY: NOT SIGNIFICANT
GENERAL EXAMINATION:
PATIENT is conscious coherent and cooperative
Speech is normal
No pallor ,icterus, cyanosis ,lymphadenopathy, edema, clubbing .
VITALS:
Temperature: 98.4°F
BP:120 /80 mmHg
PR: 80 bpm
RR : 16 cpm
SpO2 : 96
SYSTEMIC EXAMINATION:
CVS: no cardiac thrills,murmurs are heard
S1 S2 heart sounds are heard
Respiratory: NO DYSPNOEA,WHEEZE
BAE- POSITIVE
INVESTIGATIONS:
PROVISIONAL DIAGNOSIS:
RECURRENT CEREBROVASCULAR ACCIDENT
Acute ischaemic stroke, hemiparesis.
FINAL DIAGNOSIS:
RECURRENT CEREBROVASCULAR ACCIDENT
Acute ischaemic stroke, hemiparesis
TREATMENT PLAN:
IV FLUIDS
T .ECOSPRIN 20MG PO OD
T.ATORVA 40 mg PO HS
T.PAN 40 MG PO OD
