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.
This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.
Here is a case i have seen:
A 60 year old male presenting with weakness of left upper limb and lower limb since 25 dec 2020 morning.
Patient’s earliest recall of events date back to 26-dec -2020 morning. Patient was in his usual self, when he woke up around 6 am doing his daily routine. As he was having breakfast he felt weakness in his left upper limb as he was trying to hold the glass of water for few sips. As he was trying to stand he couldn’t feel the ground with his left leg. Patient at every point denies history of headache, giddiness, H/O fall, loss of consciousness. He denies history of deviation of mouth, slurring of speech.
Patient and his wife delayed presentation to nearest hospital as they thought Kamineni, Narketpally was better for treatment (in his words) and were hold back for a day and presented to casuality on 26 dec 2020 morning.
Patient has significant alcohol history. As a daily wage labourer, after day’s hard-work he often indulges himself in alcohol around 90-180 ml of whisky from the past 20 years. He is also a chronic smoker. A pack of beedi for every 2 days since he was 15 years old. His last binge was the 24 dec night
He has been also been complaining of cough on and off since 2 years
He is a K/C/O HTN since 1 year on regular medication.he used tab amlong 5mg from past one year
Not a K/C/O DM - II , TB, Asthma, CAD
General examination:
PATIENT IS CONSCIOUS,COHERENT,COPERATIVE
Obese Individual
Icterus present
Clubbing - Grade 3 Parrot beak appearance
no pallor, cyanosis,lymphadenopathy,edema
peripheral pulses present
vitals:
Patient is afebrile.
Bp: 160/100 mm Hg
PR: 76 bpm,regular rhythm,normal volume
RR: 22 cpm
systemic examination :
gait of patient
CNS:
Power
UL. LL
Right 5/5. 5/5
Left 4/5. 3/5
Tone.
Right. ⬆️. ⬆️
Left. ⬇️. ⬆️
(osteoarthritis causing ⬇️ROM)
Reflexes.
B. T. S. K. A.
Right. 2+. 2+. 2+. 2+. 2+.
Left. 3+. 3+. 3+. 3+. NA
Sensory-
Vibration, Proprioception, Fine touch, crude touch, temperature intact
Cranial Nerves - Intact
No Cerebellar signs
Autonomic- No disturbance
CVS : S1, S2 +
RS :Inspiratory crepts present in B/L IAA, ISA
Expiratory wheeze present in all the lung fields
INVESTIGATION:
chest x - ray
2d echo video
provisional diagnosis:
Left Sided Hemiparesis with ? Ischemic Stroke at Right Internal Capsule with Metabolic Syndrome associated with Chronic Smoking and Alcoholism
Chronic Bronchitis
Venous Insufficiency with Varicose Veins
DISCUSSION:
1)
Subcortical infarcts are very common
Cerebrovascular accidents are more common in subcortical areas because the perforating arteries that supply the region are predisposed to occlusion or rupture due to their small diameter.
Ischemic strokes secondary to blockage of the perforating arteries are known as lacunar strokes.
The mechanisms of lacunar strokes include
1. Lipohyalinosis of perforating blood vessels - Most common cause
2. Atherosclerosis of the large trunk vessels that supply perforators
3. Embolic occlusion of the perforating arteries.
2)
RCT on aspirin and Clopidogrel in the management of ischaemic stroke
SPARCL - STROKE PREVENTION BY AGGRESSIVE REDUCTION IN CHOLESTEROL LEVELS
* This study was conducted among 4731 patients who had a stroke or TIA within one to six months before study entry, had low-density lipoprotein (LDL) cholesterol levels (100 to 190 mg/dl) , and had no known coronary heart disease
*This was a double-blind prospective study
P- 4731 patients were included
I - 2365 patients received 80 mg of atorvastatin per day
C- 2366 received placebo.
O - During a median follow-up of 4.9 yrs, 265 patients receiving atorvastatin and 311 patients receiving placebo had a fatal or nonfatal stroke. The atorvastatin group had 218 ischemic strokes and 55 hemorrhagic strokes, whereas the placebo group had 274 ischemic strokes and 33 hemorrhagic strokes.
In patients with recent stroke or TIA and without known coronary heart disease, 80 mg of atorvastatin per day reduced the overall incidence of strokes and of cardiovascular events, despite a small increase in the incidence of hemorrhagic stroke.
MATCH Trail on Aspirin + Clopidogrel vs Clopidogrel alone in Ischaemic Stroke
7599 high-risk patients with recent ischaemic stroke or transient ischaemic attack and at least one additional vascular risk factor who were already receiving clopidogrel 75 mg/day.
A randomised, double-blind, placebo-controlled trial to compare aspirin (75 mg/day) with placebo.
Duration of treatment and follow-up was 18 months. The primary endpoint was a composite of ischaemic stroke, myocardial infarction, vascular death, or rehospitalisation for acute ischaemia
596 (15.7%) patients reached the primary endpoint in the group receiving aspirin and clopidogrel compared with 636 (16·7%) in the clopidogrel alone group. Life-threatening bleedings were higher in the group receiving aspirin and clopidogrel versus clopidogrel alone.Major bleedings were also increased in the group receiving aspirin and clopidogrel but no difference was recorded in mortality.
Adding aspirin to clopidogrel in high-risk patients with recent ischaemic stroke or transient ischaemic attack is associated with a non-significant difference in reducing major vascular events. However, the risk of life-threatening or major bleeding is increased by the addition of aspirin
TRIAL ON ASPIRIN VS PLACEBO
Patients with ischaemic stroke but not complete paresis were included. Totally, 441 patients (220 aspirin, 221 placebo) completed the trial.
The trial was randomized, double-blind and placebo-controlled.
Tablets Aspirin 325 mg or placebo, water solvable, were administered orally once a day for five consecutive days.
Neurological assessments were carried out three times daily during the treatment period to detect progression of at least two points in the Scandinavian Stroke Supervision Scale.
Patient outcome was followed up at discharge and at 3 months.Aspirin treatment did not significantly reduce the frequency of stroke progression. Amongst aspirin‐treated patients, stroke progression occurred in 15.9% as compared with 16.7% in the placebo group, which is less frequent than expected. The relative risk was 0.95 (95% CI 0.62–1.45) in the treatment group.
As regards patient outcome at discharge and after 3 months, aspirin treatment did not show any difference.
Treatment
Day 1
Inj.Optineuron 1 amp. in100ml NS IV OD AT 2 PM
INJ. THIAMINE 1 AMPOULE IN 100 ML NS TID
TAB.ASPIRIN +ATORVAS (75/20MG) PO OD AT 8 PM
TAB.CLOPITAB 75 MG PO HS AT 8PM
TAB.ULTRACET PO BD 1/2 AT 8 AM ----1/2 AT 8 PM
PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS
DAY 2
Inj.Optineuron 1 amp. in100ml NS IV OD AT 2 PM
INJ. THIAMINE 1 AMPOULE IN 100 ML NS TID
TAB.ASPIRIN +ATORVAS (75/20MG) PO OD AT 8 PM
TAB.CLOPITAB 75 MG PO HS AT 8PM
TAB.ULTRACET PO BD 1/2 AT 8 AM ----1/2 AT 8 PM
PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS
DAY 3:
Inj.Optineuron 1 amp. in100ml NS IV OD AT 2 PM
INJ. THIAMINE 1 AMPOULE IN 100 ML NS TID
TAB.ASPIRIN +ATORVAS (75/20MG) PO OD AT 8 PM
TAB.CLOPITAB 75 MG PO HS AT 8PM
TAB.ULTRACET PO BD 1/2 AT 8 AM ----1/2 AT 8 PM
TAB.TELMA- AM (40/5 MG) PO OD
PHYSIOTHERAPY OF LEFT UPPER AND LOWER LIMBS
