E LOG CASE 4 , 65 yr old male with CVA , right sided complete hemiparesis

 65 yr old male pt with CVA, right sided complete hemiparesis 

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By M.Sai Surya 

Roll.no :100 

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 icluding history,clinical findings,investigations and come up with a diagnosis and treatment plan.

Coming to the case , 

65/M with C/O : inability to speak since evening (around 6pm.) on 3/3/2021

Deviation of angle of mouth to left side since evening .

Patient was apparently alright till evening, suddenly he was unable to speak with deviation of angle of mouth to left side. 

No h/o weakness of upper and lower limbs.

No h/o fall / LOC.

No h/o involuntary movements.

No h/o nausea/ vomiting/ fever 

Past history: 

✔️No h/o DM /HTN /TB /Asthma /Epilepsy /thyroid abnormalities /CAD

✔h/o appendicecty in the past (30years back)

Personal history : 

Diet - mixed

Appetite - normal 

Sleep - adequate 

Bowel and bladder movements - regular 

Takes alcohol occasionally 

Not a smoker

Family history :

No significant family history 

Drug and allergic history :

No known drug and allergic history 

On examination : 

Patient is conscious, coherent and cooperative 

Moderately build and nourished 

Deviation of angle of mouth to left side.

No pallor/icterus/cyanosis/clubbing/generalised lymphadenopathy/ pedal Edema 

Vitals : 

BP: 110/70mmhg

PR: 98bpm

RR: 18cpm

SPO2: 98% at RA

Afebrile to touch

Systemic examination: 

CVS: s1,s2 heard, no murmurs 

RS: BAE present, no added sounds 

P/A: soft, non - tender 

CNS: 

Patient is oriented to time, place, person, and self 

Speech is slurred 

Cranial nerves : intact except VII and Xl

Increased tone in right upper limb

Power : 

              Right. Left 

       UL. 3/5. 4/5

       LL. 4/5. 4/5

Reflexes 

            Right. Left

Biceps. 3+ 3+

Triceps. 3+ 3+

Supinator. 0. 0

Knee. 2+ 2+

Ankle. 3+ 3+

Plantar. Withdrawal. Palmar flexion 

Investigations : 

X ray : 

Colour Doppler 2D echo : 

 

Hb: 12.2 g/dl

MRI report : 

Diagnosis : 

Acute ischemic stroke - acute infarct in left frontal and parietal lobes and left insular cortex , left sided deviation of mouth may be due to middle cerebral artery pathology .