65/M with slurring so speech

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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 come up with diagnosis and treatment plan



Chief complaints


c/o slurring of speech since today morning

Deviation of mouth to Right side since today morning

Weakness of left upper limb since today mornin


 Hopi


Patient was apparently alright 6months back then he had h/o loose stools 6-7 episodes daily low quantity,yellow in colour not associated with pain abdomen,no mucus in stool,no blood in stools


H/o fever 2 episodes in the past 6 months and not releived by taking medication no h/o nausea,vomitings,h/o decreased appetite since 6 mont


Patient brought to opd with c/o slurring of speech,deviation of mouth to right side and weakness of left upper limb since today morning


Pt was normal when he woke up and he suddenly developed weakness of left UL ,slurring of speech and deviation of mouth to right sid


No h/o cold ,cough,seizure,headache,blurring of vision,diplopia, vertigo , dizziness or parasthesisas.

K/c/o HTN Since 7years on medication (Telma-H 40mg )

sleeps adequately. diet is mixed and has a good appetite. 

Drinks alcohol ocassionally in the past  but stopped totally from 2 month

Smoker since 40years


Patient is conscious,coherent,cooperative

Vitals normal

Afebrile

Spo2:98%@

 pallor+

All systemic examination were normal except

CNS Examination
































Diagnosis - CVA ( hyperactute infarcts in right frontal lobe ) 


TREATMENT


T.CLOPIDOGREL 75 MG PO/


T.ECOSPRIN 75MPO/


T.ATORVOSTAT 20MG PO/


INJ.OPTINEURON in 100ml NS IV ST


INJ.ZOFER 4MG IV ST


IV FLUIDS NS,RL@100ml/hr ATATODODODT:A s:



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