A 65 year old male patient presented with weakness in the right side of the body

November 29, 2022

E LOG GENERAL MEDICINE.

Hi, I am G Sai Karthik, 3rd Sem Medical Student. This is an online e-log book to discuss our patient's health data shared after taking his/her/guardian's consent . This also reflects patient centered care and online learning portfolio.

This E-log book also reflects my patient-centered online learning portfolio and of course, your valuable inputs and feedbacks are most welcome through the comments box provided at the very end. HAPPY READING.
* This is an ongoing case. I am in the process of updating and editing this ELOG as and when required
CASE SHEET.
Chief complaints and duration.
A 65 year old male patient presented with weakness of left upper limb and lower limb since yesterday and tingling sensation in the right upper limb and generalised weakness since 20 days.
History of present illness.
The patient was apparently asymptomatic and alright till twenty days back when he developed tingling sensation right upper limb which gradually progressed. He developed generalised weakness for which he was taken to the hospital and investigations were done for MRI. Since yesterday he developed tingling sensation of left upper limb and lower limb and slurring of speech.
History of past illness.
H/O cerebrovascular accident (stroke) 6 years back
K/C/O hypertension since 6 years on medication
Tab Telmisartan(40mg)+
Tab Almodioine(5mg)
K/C/O DM since 5 years on medication
Tab Metformin (250mg)
H/O Hypertensive emergency 2 months back.
N/K/C/O asthma , epilepsy, Tb
Personal history.
Appetite normal
Bowel movements regular
No burning Micturition
Sleep inadequate last night
Addictions : Regular Alcohol consumption stopped 3 years back.
Family history.
No significant family history.
PHYSICAL EXAMINATION.
A. General Examination
Pallor is present.
Icterus is absent
No cyanosis
No clubbing of fingers
No lymphadenopathy
No malnutrition
No clubbing of fingers
No oedema of feet and hands.
SYSTEMIC EXAMINATION
B. Cardiovascular system
No thrills
No cardiac murmurs
Cardiac sounds: S1 and S2
C. Respiratory system
dyspnea absent
No wheezing
No Vesicular breath sounds .
Position of trachea - central
D. Abdomen
Abdomen is scaphoid
No tenderness
No Palpable mass
Bowel sounds anew present
No bruits
No free fluids
E. Central nervous system
The patient was conscious coherent and cooperative with
Slurry speech
Investigations:
USG and MRI
USG report:
acute infarct in cingulate gyrus - right side.
Chronic infarct in left basal ganglia.

Provisional diagnosis: Left hemiparesis.