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55 yr male with weakness in left UL/LL

 Pravallika Gade , MBBS 3rd semester

Roll no: 41 

Under the guidance of Dr. Sai Vittal sir (Intern)


This is an online E-log book to discuss our patient's identified health data shared after taking his/ her guardians signed informed consent.

 

Here we discuss our individual patient problems through a series of inputs from available Global online community of experts with an aim to solve the patients  clinical problem with current best evidence based input.

 

This E-log also reflects my patient centered online learning portfolio.

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 a diagnosis and treatment plan.


CASE SCENARIO:

A 55 year old male patient presented to the casuality on (when) with chief complaints of weakness of movements of left upper and lower limbs, deviation of mouth to right side, slurring of speech, difficulty in swallowing , drooling from left side of mouth and involuntary micturition.


HISTORY OF PRESENT ILLNESS:

Previous visits to any hospital with same illness??

No H/O of involuntary movements, fasciculations an sensory loss.


PAST HISTORY: 

K/C/O DM Type II since 9 months

Denovo HTN


TREATMENT HISTORY:

On medication for DM 

Tab. Metformin  500 mg  OD

         Glimi  2 mg  OD

         Voglibose 0.2 mg  OD


SURGICAL HISTORY:

No relevant history


PERSONAL HISTORY:

Married

Occupation: Farmer

Diet: Mixed , Non vegetarian 

Appetite: Decreased

Sleep: Adequate

Bowels: Irregular

Allergies: No 

Addictions: No


FAMILY HISTORY:

No H/O similar complaints in the family 


PHYSICAL EXAMINATION:

Patient is conscious and coherent

Moderate built and moderately nourished

Well oriented to time, place and person.

No pallor

No icterus 

No cyanosis 

No clubbing 

No lymphadenopathy

No edema


VITALS:

Temperature: Afebrile

Pulse rate:102 bpm/min

BP:140/100 mm Hg

Respiratory rate: 20cpm/min

SpO2: 96%



SYSTEMIC EXAMINATION:


CVS EXAMINATION:

Thrills: No

Cardiac sounds: S1 , S2

Cardiac murmurs: No


RESPIRATORY SYSTEM:

Dyspnoea: No

Wheeze: No

Position of trachea: Central 

Breath sounds: Vesicular 

Adventitious sounds : No


ABDOMEN EXAMINATION:

Shape of abdomen: Scaphoid

Tenderness : No

Palpable mass: No

Hernial orifices: No

Free fluid: No

Bruits: No 

Liver: Not palpable

Spleen: Not palpable 

Bowel sounds: Yes


CNS EXAMINATION:

Level of consciousness: Conscious and alert

Speech: Slurred

Signs of meningeal irritation:

  1. Neck stiffness: No

  2. Kerning’s sign: No

Cranial nerves: Deviation of mouth towards right side 

Motor system:

Power     R     L

UL         5/5   0/5

LL          5/5   0/5


Tone       R                   L

UL       Normal       Decreased

LL       Normal        Decreased


Reflexes 

                       Biceps          Triceps        Supinator        Knee        Ankle

RIGHT             +                    +                    +                    ++            ++

LEFT                +                    +                    +                    ++            ++

Plantars : Extensor


Cerebral Signs: 

Finger nose In-coordination : Yes (+) on right side

Knee Heel IN-Coordination:  Yes (+) on right side


INVESTIGATIONS:

Haemogram, CUE. ECG, CXR- PA view ,RFT , LFT, HBA1C , FBS , PLBS


HAEMOGRAM




LFT


 



FASTING BLOOD SUGAR




CXR - PA VIEW


MRI MIDBRAIN


BACTERIAL CULTURE AND SENSITIVITY REPORT





RENAL FUNCTION TEST




COMPLETE URINE EXAMINATION




HBA1c




PROVISIONAL DIAGNOSIS:

HEMIPLEGIA secondary to ACUTE INFARCT in B/L  corona radiata, left side caudate nucleus and right frontal lobe

PRE- RENAL AKI

K/c/o DM II since 9 months


TREATMENT:

  1. IV fluids NS and RL @ 100 ml/hr

  2. Tab. ECOSPRIN 150 mg PO/OD

  3. Tab. CLOPITAB 75 mg PO/OD

  4. Tab. ATORVAS 20 mg PO/HS

  5. Tab. PANTOP 40 mg PO/OP

  6. Tab. Tab. Metformin  500 mg + Glimi  2 mg + Voglibose 0.2 mg PO/OD

  7. Physiotherapy  of left upper and lower limbs

  8. I/O charting

  9. BP/PR/TEMP monitoring


Thank you Dr.Rakesh Biswas sir for this opportunity.



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