A 74year old female presented with right sided weakness

This is an online E log book to discuss our patient’s de-identified health data shared after taking

his/her/Guardian’s sign 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 collecting current best evidence-based inputs.

    Patient was apparently asymptomatic 10 years ago then she had met with RTA and had history of left forearm fracture , from then onwards she had ℅ weakness of left upper limb

Head injury unknown 

Then 10 days back she had H/o fall while going to washroom,unconsciously 

℅ weakness of right upper limb and lower limb and deviation of mouth to left side

She also had ℅ seizures at time of fall

She also had similar episodes 7-8 times since then

No ℅ head ache,nausea,vomiting

She is able to recognise faces

Decreased appetite,significant weight loss present

No ℅ fever ,cold,cough

Speech slurred

No h/o Htn,dm,epilepsy,asthma,tb,cva,cad

GCS-15/15

Tobacco chewer since 50 years

Alcoholic occasional since 50 years 

no history of involuntary movements, drooling of saliva,tongue bite,chest pain,SOB,pedal edema,fever,vomitings,loose stools,pain abdomen, micturition.

General Examintaion:

Patient is conscious,coherent and well oriented

Temperature:afebrile

Pr:92bpm

Bp:120/80mm hg

SpO2:98 at room air

Rr:18cpm

Cvs:s1s2 heard 

Rs:bae+,nvbs

Per abdomen :soft ,non tender

Cns:alert,

Speech slurred

Reflexes:

               Biceps triceps supinator knee ankle

Right.    ++.        ++.           ++.       ++.    +

Left.        +.         +.              +.         +.     +

Plantars extensor right side, neutral on left

Finger nose in  coordination -no

Knee heel in coordination-no

Motor system- R L

Power UL 3/5 4/5

LL 3/5 4/5

Tone UL Increased Decreased

LL Increased Decreased

INVESTIGATIONS:

Treatment:

Day 0:

TAB ECOSPRIN 75 mg po\od

TAB ATORVAS 20 mg po/hs

INJ OPTINEURON 1 amp in 100 ml NS IV BD

TAB MVT

physiotherapy of right upper limb and lower limb

Bp,Pr,spO2,RR CHARTING 6th hourly

Physiotherapy of all four limbs

Syp lactulose 10 ml /po /bd

Day 1:

TAB ECOSPRIN 75 mg po\od

TAB ATORVAS 20 mg po/hs

INJ OPTINEURON 1 amp in 100 ml NS IV BD

Tab.Leviteracetam 500mg po/bd

TAB MVT po od

physiotherapy of right upper limb and lower limb

Bp,Pr,spO2,RR CHARTING 6th hourly

Physiotherapy of all four limbs

Syp lactulose 10 ml /po /bd

Day 2:

TAB ECOSPRIN 75 mg po\od

TAB ATORVAS 20 mg po/hs

INJ OPTINEURON 1 amp in 100 ml NS IV BD

Tab.Leviteracetam 500mg po/bd

TAB MVT PO OD

physiotherapy of right upper limb and lower limb

Bp,Pr,spO2,RR CHARTING 6th hourly

Physiotherapy of all four limbs

Syp lactulose 10 ml /po /bd

Day 3:

TAB ECOSPRIN 75 mg po\od

TAB ATORVAS 20 mg po/hs

INJ OPTINEURON 1 amp in 100 ml NS IV BD

Tab.Leviteracetam 500mg po/bd

TAB MVT PO OD

physiotherapy of right upper limb and lower limb

Bp,Pr,spO2,RR CHARTING 6th hourly

Physiotherapy of all four limbs

Syp lactulose 10 ml /po /bd

Day 4:

Tab ECOSPRIN 75 mg/po/od

Tab ATORVAS 20 mg po /hs

Tab MVT PO/od

Physiotherapy of right upper limb and lower limb

Tab Pan 40 mg od 

Tab LEVITRACETAM 500 mg po bd

ATT STARTED