Case: 70 yr old with sudden onset aphasia

 Neha Pradeep, MBBS 9th semester




Roll no: 99




This is online E log book to discuss our patient’s de-identified health data shared after taking his/her/guardian’s signed 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 patients 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 comment box is welcome .




I’ve 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. 




Following is the view of my case :


Case: 70 year old man with sudden onset aphasia


History of Presenting Illness: 

Patient was apparently asymptomatic till yesterday. He woke up from bed at 11 p.m. to go to washroom and fell from the bed. 

He was unable to talk or understand words and he was unable to wake up from the floor.

There is no history of trauma to the head, no involuntary micturition or defecation.

Patient has complaint of fever since 5 days. Fever is sudden in onset and non progressive. Not associated with chills and rigors. No nausea, vomiting, headache or blurred vision. No complaints of shortness of breath, edema or burning micturition.  

Past History: 

Patient has no similar complaints in the past. 

He is a known case of diabetes and hypertension since 1 year. He is irregular with medication. 

No history of asthma, tuberculosis or epilepsy. 

Personal History: 

Diet: Mixed

Appetite: Normal

Sleep:  Adequate

Bowel and Bladder: Regular

Occasional alcohol intake (about 90ml) since 10 years.

Smoker since 50 years, smokes one packet a day. 


General Examination: 

Patient is conscious, not coherent, not cooperative. 


Vitals: 

Temp : 98.6F

BP: 140/90

PR: 114

RR: 28

Spo2: 99% on 6lit of 02



CVS: S1,S2 heard 

RS: BAE +,NVBS 


Abdomen: soft , nontender

Bowel sounds heard

CNS : patient is conscious, not coherent, cooperative






GCS -9/15

  Neck stiffness is present. Kernigs sign is negative.

Motor system: 

                                        Right     Left 

Tone: Upper limbs          N          N

           Lower limbs          N        N 

Power: Upper limbs     4/5       4/5

              Lower limbs     4/5        4/5 


Reflexes: B     T     S     K      A 

Right       +2.   +2.    -       -       -

Left          +2    +2     -      -       -




Total bilirubin: 4.66 mg/dl
Direct Bilirubin: 2.42 mg/dl
SGOT: 77 IU/L
Total Proteins: 4.5 gm/dl
Albumin: 2 gm/dl
Alkaline Phosphate: 732 IU/L

Urea: 100 mg/dl
Creatinine: 1.5 mg/dl






CT Scan: 




Observations from CT: 

Tiny lacunar infract in head of caudate on left side. 

Diffuse cerebral atrophy. 







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