Male with inability to speak

 Hello all this is G Jagadeesh,a eight semester student.This E Log depicts the patient centered approach to learning 

This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's 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 patient's clinical problems with collective current best evidence based inputs. 

Note : This is an on-going case and will be updated as and when I receive any information. 

Patient was brought to the casualty with complaints of inability to speak since 6 hrs, weakness in right upper and lower limb since 6 hrs and deviation of angle of mouth to left since 6hrs.

HOPI : Patient was apparently asymptomatic 6hrs back ,then he developed inability to speak since 6 hrs, weakness in right upper and lower limb since 6 hrs and deviation of angle of mouth to left since 6hrs.

No h/o fever, seizures

Past history:

History of CVA 2 years back.He got admitted in a local hospital and recovered.

History of hydrocele surgery 6months back

N/k/c/o DM

Personal history:

Mixed diet,normal appetite,sleep Adequate,bowel and bladder movement regular

Addictions - alcoholic and smoker for 30 years

General examination 

Patient is conscious 

PR- 104 bpm

RR-20 cpm 

BP-130/70 mm of Hg

Spo2 -92% on room air

Grbs- 126 mg/dl

Input/Output - 2800ml /1050ml

CNS Examination 

GCS- E4 V1 M5

Pupils - B/L NSRL

Reflexes

      Rt Lt

B - 3+. 3+

T - 3+. 3+

S- 2+. 2+

K - 3+. 3+

A - 2+ 2+

Plantar 

Right-Extensor Left-Flexor 

Tone- normal in all 4 limbs

Power - 2/5 in right upper and lower limb

4/5 in left upper and lower limb

RS-B/L air entry present ,grunting present 

CVS- S1S2present, no murmurs heard

PA- soft,non tender,bowel sounds +

Provisional diagnosis

Recurrent CVA with acute infarct in left frontal and temporal lobe with chronic lacunar infarcts in bilateral capsuloganglionic region with aspiration pneumonia with hypokalemia( secondary to ? Nutritional) with Hypertension since 3 years 

Treatment 

1.Ryles tube feeds- 200ml water hrly,200ml milk 4rth hrly

2.IV FLUIDS NS, RL @ 50 ml/hr 

3.TAB. ECOSPRIN 75mg RT/OD

4.TAB.CLOPIDOGREL 150mg RT/OD

5.TAB.ATORVASTATIN 40mg RT/OD 

6.Tab.AMLONG 5mg PO OD 

7.Physiotherapy

8.Monitor vitals

9.Position change 2nd hourly