63 M WITH RECURRENT STROKES SINCE 2009

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This is an E log book to discuss our patients de identified health data shared after guardians informed consent.

Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve this patients clinical problems with collective current best evidence based inputs.

This E-book also reflects my patients centered online learning portfolio and your valuable comments in comment box are most welcome.

I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency and to comprehend clinical data including history, clinical finding investigations and come up with a diagnosis and treatment plan.


CHIEF COMPLAINTS 
- Deviation of the mouth to the left since 2 weeks 
- Increased urgency of urination since 2 weeks 
- slurring of speech since 2 weeks 

HISTORY OF PRESENT ILLNESS: 
The patient was apparently all right two weeks ago then he was at a family gathering, where he took alcohol and after 2 days he developed deviation of the mouth to the left side and could not speak properly and only communicated with hand gestures. 
He also had an increased urgency to urinate and often urinated on the way to the bathroom which reduced now to a certain extent. 
No history of trauma, seizures, fever, chest pain 
No dysphagia, dysarthria, LOC, blurring of vision
PAST HISTORY:
The patient had similar complaints in the past first one being in 2009 and the second episode in 2020 
History of hypertension since 2009 on Tab Telma 40 mg 
No h/o diabetes, epilepsy, tuberculosis, asthma, thyroid disorders 
Daily routine:
Personal history: 
Diet: mixed 
Appetite: normal 
Sleep adequate 
Bowel and bladder: increased urgency, no burning micturition 
GENERAL EXAMINATION
The patient is conscious, coherent, cooperative 
Slight lisp present while speaking 
Moderately built and nourished 
No signs of pallor, icterus, cyanosis, clubbing, edema, lymphadenopathy 
Vitals: 



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