Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬

Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

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Date patient arrived: 1/5/2023

(DD/MM/YY)

Patient’s location: Male medical word Source of referral ER/OPD/Other……………

Clerking student: Mohammed Abed Al Sehli Module: C

Date of clerking: 5/5/2023 Hospital: King Faisal hospital

Doctor reviewing case:

Source of history
Patient, relative, interpreter etc.
Patient’s son

Chief complaint(s) [CC]

Left sided weakness for 3 hours

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Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

History of each Presenting Illness [HPI]

Include chronological sequence of each complaint; systems specific review; risk factors including related PMH;
relevant negatives, and complications

50 years old Saudi male patient known case of HTN and DM on

medication. Admitted through ER complaining of left sided weakness for
3 hours.

The weakness started suddenly constant in left side of the body and the
face. Patient feels that its more in the upper limb than lower.the patient
said that its a ecting his daily activity like get in up the bed.

The weakness is associated with numbness in the left side of the body
and the lower left of the face for 3 hours, nausea for 2 hours, di culty in
articulating words but can understand and follow command, and fatigue
started with the weakness.

There no history of fever, anorexia, loss of weight, or night sweating There

is no headache, nick sti ness, photophobia , preceding aura, loss of
consciousness or seizure.

There is no chest pain, palpitation, syncope, dyspnea, orthpnea,

abdominal pain, change in bowel habit, diarrhea, dysuria or hematuria.

There is no history of trauma or traveling

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Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Past Medical, Surgical and Mental History [PMH]

Previous surgeries:
None Include dates/operations
Cardiovascular problems
Respiratory problems
Hepatic problems
GI problems No previous surgeries
Renal problems
Neurological problems
Diabetes mellitus
Type1
Type 2

(N.B. insulin treatment does not necessarily =

T1DM)

Malignancy

Any other conditions/details:

HTN for 10 years on amlodipine.

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Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Drug History [DH]

Include dose/frequency/self-medication/over the counter OTC medication/ inhalers/ oxygen /nebulizers

Medication Dose Route Frequency

Amlodipine 5mg PO Once daily

Others:

Allergies and adverse reactions

Include details of reaction

No drug or allergic history

Family History [FH]

His father has DM type 2

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Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Social History [SH]

Smoking status
Current smoker Alcohol consumption No
per day for years
Ex-smoker Recreational drugs: No
Never smoked

Recent foreign travel (if relevant)

Occupation:

He is retired from army

Patient or carer’s concerns, expectations and wishes

The patient concerns about having a serious issue, and she doesn’t expect any thing.
She wishes to have the optimum plan of care, to investigate her problem, reach a
final diagnosis and treated properly.

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Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Systems Review [SR]

Tick and write details alongside

General CVS GU
Weight loss Chest pain Haematuria
Night Palpitations Dysuria Frequency
sweats
Voiding difficulty
Fevers SOB
PV discharge
Rashes PND Reminder before x-ray
Mood Ankle
Date of last menstrual period / /
edema

RS Other relevant history:

Cough
None
Sputum
Hemoptysis
Wheeze
Exercise tolerance

GI
Appetite change
Vomiting
Hematemesis/ melena
Rectal bleeding
Bowel habits (any change?)
Abdominal pain

CNS
Headaches
Visual disturbances
Syncope
Weakness
Paraesthesia
Fits/syncope

Locomotor
Joint pain
Stiffness
Swelling

Case Summary

50 years old saudi male patient known case of HTN came to ER

complaining of left sided weakness associated with numness in the left
side of the body and lower part of the face. No fever ,no headache.

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 Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

On Examination [O/E]
Vital Signs: O2 Sat:98% on room airRR: 18 bpm HR: 83 bpm BP: 130/75 Temp:36.5°C
Observations: Blood glucose: 103 mg/dl GCS: E V M 15 /15

Pie
Urine Output : ml/hour
General appearance: well / ill
He looks ill ,overweight BMI:28
palethere is no skin
/ cyanosed rash in /the
/ clubbed hand or/face,
jaundiced No bruises
lymphadenopathy
Cardiovascular System [CVS]:

Capillary refill time (normal<2s): Normal

Pulse: 83 bpm, normal rate regular rhythm
Peripheral pulses and bruits: Normal, no radio-radial delay or radio-femoral delay, no bruit
BP (RT/LT arms): RT arm 130/75 mmHg, LT arm 130/75 mmHg
BP (erect/supine): Erect 130/75 mmHg, supine 129/76 mmHg
Jugular venous pressure: Normal jugular venous pressure (3cm) above sternal angle
Apex beat, trills, heart sounds: No shifting of apex beat, S1, S2 no thrill and no murmur.
Ankle edema: No

Respiratory System [RS]:

Respiratory rate: 18 bpm
Trachea/position: Centralized, no deviation
Expansion: Equal bilateral expansion
Percussion notes: Resonant
Breath sounds: Normal vascular breathing bilateral over all the chest.
Added sounds: No crepitation or wheezing.

Gastrointestinal System [GI]:

Distension: No
Scars:No
Tenderness: It was generally soft and lax on palpitation, no tenderness
Guarding: No
Palpable organs: No organomegaly
Bowel sounds:Normal bowel sound
Ascites: No

Hernial orifices: No
Rectal Examination:
Indicated: Yes/No
Findings: Inspection/tone/sensation/prostate/stool/melena

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 Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Nervous system [NS]:

☐ Nervous system examination is not indicated on this admission for this patient
Cognitive Function: Patient is conscious (glasgow coma scale 15/15),
No abnormal findings in his short & long memory, speech, cognitive, or orientation
Cranial nerves [CN] Right Left
I Normal Normal
II Acuity Normal Normal
Pupils Normal Normal
Fields Normal Normal
III, IV, VI Normal Normal
V Normal Normal
VII Normal Numbnees in the lower of the face otherwise normal

VIII Normal Normal

IX-XII Normal Normal
Fundi Intact Intact

Upper limb Right Left

Tone (↓/N/↑) Normal Normal
Power (0-5)
Shoulder Abduction (C5) 5/5 2/5
Adduction 5/5 2/5
Elbow Flexion (C5/C6) 5/5 2/5
Extension(C6-C8) 5/5 2/5
Wrist Flexion 5/5 2/5
Extension (C7) 5/5 2/5
Fingers Flexion (C8) 5/5 2/5
Extension (C7) 5/5 2/5

Coordination: Finger-nose test: normal. Alternating movement: normal.

Lower limb Right Left

Tone (↓/N/↑) Normal Normal
Power (0-5)
Hip Flexion (L1/L2) 5/5 3/5
Extension (L5-S2) 5/5 3/5

Knee Flexion (L5/S1) 5/5 3/5

Extension (L3/L4) 5/5 3/5
Ankle Dorsiflexion (L4/L5) 5/5 3/5
Plantarflexion (S1) 5/5 3/5
Coordination: Heal to shin test: normal

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 Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Reflexes (+++/++/+/-) Right Left

Biceps (C5/C6) ++ ++
Supinator (C5/C6) ++ ++
Triceps (C7) ++ ++
Knee (L3/L4) ++ ++
Ankle (S1) ++ ++
Plantar Normal Normal

Sensation of upper limb: No sensation over the the hand and

arm

Sensation of lower limb: No sensation over the sole of the foot

Gait: Left side ataxia

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Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Special Exams:

-ve meningeal signs

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Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Differential Diagnosis [DDx]:

• Ischemic stroke
• Heamorgic stroke
• Multible sclrosis

Working Diagnosis [DDx]:

Stroke

Problem List:

The problem list is not the same as the differential diagnosis. It should include all problems
related to the patient’s acute presentation, chronic diseases, smoking/alcohol status, any
concerns or expectations.

• DM type 2
• HTN
• Left side
weakness,numbness,
Nausea, speach deficulty
and fatigue.

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 Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Initial Investigations [Ix]:

Blood results:
CBC shows:
Results Normal ranges
Hemoglobin (g/dL) 13 12-15
RBC (106/μL or 1012/L) 4 3.8-4.8
Hematocrit (%) 35.1 36-46
MCV (fL/cell ) 84.4 83-101
MCH (pg/cell) 29.1 27-32
MCHC (g/dL) 32.3 31.5-34.5
WBC (103/μL) 8 4-10
Platelets (109/L) 314 150-400
RDW (%) 7 < 15

Chemistry shows :
Results Normal ranges
Na (mmol/L) 139 1.37-145
K (mmol/L) 3.9 3.5-5.1
Cl (mmol/L) 102 98-107
Creatinine (mmol/L) 71 60-110
BUN (mmol/L) 3.34 3-8
TBIL (umol/L) 12 0-21
DBIL (umol/L) 1.4 0-3.4
LDH (U/L) 150 135-214

Coagulation profile shows:

Results Normal ranges
APTT (sec) 30 26–40
PT (sec) 14.7 11.5–15.5
INR (sec) 1.09 0.9–1.2

Imaging:
X-Ray: Not done CT scan: ECG:
Witout contrast showed Normal regular rhythm
hypodense infarction in the
PBF: right meddle cerebrum.
Not done

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 Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Management Plan:
ABCD

Admisseion to medical word

Immediately thrombolytic adminstration with alteplase

Non pharmacological
1-high risk of VTE need prophylaxis
2-Blood work
CBC, Chemistry, Coagulation profile, Lipid profile
3-Order TransThorasic Echogram
4-IV fluid adminstration
5-activety level: bed rest
Pharmacological
1-alteplase 7mg IV

Has your management plan considered the following?

1. Diet
2. Activity level
3. Non-pharmacological plan: VTE/ urgent referral, Laboratory tests /Imaging,
Microbiology e.g. swabs, blood cultures, sputum
4. Pharmacological plan, including fluids/medication
5. Follow up plan, if applicable

Confirm management plan with senior

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 Umm Al Qura University ‫ﺟﺎﻣﻌﺔ أم اﻟﻘﺮى‬
Faculty of Medicine ‫ﻛﻠﯿﺔ اﻟﻄﺐ‬

Medical Student Progress Note

Date & Time Daily Progress Notes
Diagnosis & Active Problems:
8/4/2022
Right meddle cerebral artery infarction.
10 am • DM type 2
• HTN

4/5/2023 S:
10:00 am 50 years old saudi male patient known case of HTN came to ER complaining
of left sided weakness associated with numness in the left side of the body
and lower part of the face. No fever ,no headache.

O:
Vital signs: RR: 18 O2sat: 97% on room air. Temp:37.2 BP:129/77 HR:77
on local examination:
Neuro: cranial nerves examination normal but there is loss of sensation in the
lower of the face
Weakness in the upper limb power is 2/5
and in lower limb power is 3/5
and numbness in the left side of the body
Chest: equal bilateral air entry.
CVS: normal S1+S2+0
Abdomen: soft lax abdomen, no tenderness
X-ray: normal chest X-ray
ECG:normal sinus rhythm

Assessment:
Today on rotation patient seen oriented and conscious and become better.

Plan:
Keep patient on this medication:
Aspirin 81mg orally once daily for 14 day
Omeprazole 40mg IV once daily
Amlodipine 10mg orally once daily
Enoxaparin 40mg SC once daily
Rosuvastatin 20mg orally once daily
Perindopril 10mg orally once daily
-Follow up with physiotherapy

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