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

 E LOG GENERAL MEDICINE.

Hi, I am Anvitha, 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.

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