60Y /F WITH RIGHT UPPER AND LOWER LIMB WEAKNESS WITH DEVIATION OF MOUTH TO LEFT
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 patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
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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 coming up with diagnosis and treatment plans. is an online e-log book to discuss our patient's de-identified health data shared after taking his / her / guardians' signed informed consent. Here we discuss our individual patients' problems through a series of inputs from the available global online community of experts with an aim to solve those patients' clinical problems with collective current best evidence-based information.
This is a case of 60y old female brought to casualty with c/o loss of consciousness since 1 hour,right lower and upper limb weakness since today afternoon ,deviation of mouth towards left side .
History of presenting illness
Patient was apparently asymptomatic till today when patient attender came to home patient was in unconscious state ,with right lower and upper limb weakness, with deviation of mouth towards left .
No h/o head ache ,fever ,vomitings
Past history:
Patient had similar episode 5 years back and was treated here advised for referring to higher centre but due to financial status they went to local hospital and was given medication and then she recovered.
K/C/O hypertension since 30 years
N/k/c/o DM,CAD,TB ,EPILEPSY
PERSONAL HISTORY:-
Diet - mixed
Appetite- normal
Sleep - adequate
Bowel and bladder -regular
Addictions- none
Family history:- no significant family history
GENERAL EXAMINATION:-
Patient is drowsy ,in coherent
PALLOR absent
ICTERUS absent
CLUBBING absent
CYANOSIS absent
LYMPHADENOPATHY absent
EDEMA absent
SYSTEMIC EXAMINATION :
CVS -S1,S2 heard
RESPIRATORY SYSTEM -Bilateral air entry present
P/A -Soft,Non tender
CNS examination:
Patient is drowsy ,incoherent,but arousable
Bp-160/90 mmHg
Pr-88 bpm
Rr-22 cpm
GCS -E3V2M5
Pupils-both mildly reacting to light
Power: right. left
U/l. 0/5. 3/5
L/l. 0/5. 3/5
Tone.: right. . Left
U/l. Increased normal
L/l. Increased. Normal
Reflexes: right left
B. +++. +++
T. ++. ++
S. +. +
K. +++. +++
A. ++. ++
P increased. Increased
Hemiplegic gait
Investigations
MRI BRAIN :
Diagnosis:
ACUTE HEMORRHAGIC STROKE ?
WITH K/C/O HTN SINCE 30 YEARS
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