55M with Rt upper limb & lower limb weakness with k/c/o DM and HTN.

 This is an 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 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. 


55 years old male presented with complaints of weakness of right upper limb and lower limb since 1 day and tingling & numbness of right upper limb and lower limb since 1 day.

Patient was apparently a symptomatic one day back when he suddenly after getting up from bed, patient felt difficulty in walking, right-sided weakness of upper & lower limbs associated with tingling and numbness which is acute onset non-progressive with deviation of mouth to left.

no loss of consciousness 

no seizures no difficulty in swallowing 

no bowel and bladder abnormalities 

able to do these activities like combing hair, buttoning & unbuttoning Of shirt, climbing stairs, rolling over bed, slippage of chapel was present 

no history of fever,trauma,vomitings and diplopia.

K/c/o HTN since 8 years on T. Telma AM 40/5mg OD 

K/c/o DM since 3 months on Glimi-M1 OD 

N/k/c/o CVA,CKD,Asthma


O/E: 

Pt c/c/c

Bp 140/80mmhg

PR : 78bpm

Pedal edema +





CVS : S1,S2 heard, apex beat Lt 5 ICS midclavivular, no murmurs.

Rs : BAE+, all lung zones are clear on auscultation.

P/A : soft & non tender, no organomegaly, bowel sounds+

CNS: 

HMF INTACT, oriented to time,place,person.

B/L pupils reactive to light.

Palmer grip 100% in both hands.

                             Rt                         Lt

Tone  UL              N                          N

          LL               N                         N

power   UL           5/5                       5/5

             LL           4/5                       5/5

Reflexes 

Biceps       3+             2+

Triceps      2+             2+

Supinator   2+             2+

Knee          3+             3+

Ankle         1+             1+

Planter        ?E             F

No cerebellar signs

No meningial signs

Sensory system intact.


CBP : 





CUE : 




USG ABDOMENM 




Sr. Electrolytes:



Sr. Creatinine :





Hba1c : 



ECG :



Graphical time line : 


CT BRAIN (OUTSIDE)



Treatment: 


Inj. Optineuron 1amp in 100ml NS iv OD 


Tab. PAN 40 mg OD


Tab. Metformin 500mg OD 


Tab. Telma-am 40/5 mg OD 


Tab. Clopitab-A 75/150 mg OD HS


Tab. Atorvas 4omg HS


Physiotherapy of Rt upper limb & lower limb.


Vitals & grbs monitoring.



Comments

Post a Comment

Popular posts from this blog

DISSERTATION 2020-2022.

Image
DISSERTATION  Dr. Saicharan Kulkarni pgy1 ( 2020 ) TITLE OF THE TOPIC :   CLINICO-RADIOLOGICAL PROFILE, RISK FACTORS AND OUTCOMES IN PATIENTS WITH MOTOR WEAKNESS BRIEF RESUME OF THE INTENDED WORK Problem Representation  1)The repercussions of paralysis/weakness are enormous, both personally to the individual and to their family; and have huge economic costs to society. Paralysis takes many forms with multiple disorders causing paralysis, and multiple body systems often affected. (1,)   2) Motor learning is considered crucial for rehabilitation in general. In stroke, motor learning does not refer to the acquisition of new skills, but to the re-learning process of a previously acquired movement pattern .(2)   3) 3.  Though both clinical evaluation and MRI are complimentary in detection and precise localization of the level of lesion in patients with cervical myelopathy, there is paucity of data comparing segment specific clinical features with the MRI abnorm...
Read more

65M with Recurrent CVA with visual hallucinations and k/c/o pulmonary Koch’s

Image
 A 65-year-old male patient with known case of recurrent CVA presented with complaints of seen the faces, increased appetite and urinary incontinence since 2 months Visual Hallucinations are sudden in onset associated with the ringing sensation in ears and hearing voices from surroundings Patient was apparently a symptomatic six years back then he developed generalised weakness and giddiness for which he went to local doctor and diagnosed with diabetes and on OHA, then few months later he diagnosed with hypertension and on atenolol 50mg since 3yrs History of first CVA attack 5 years back for which she went to hospital and managed conservatively and on dual antiplatelet TS for few weeks. Then 4 years back he developed low-grade fever associated with productive cough and generalised weakness. For which he was diagnosed with pulmonary tuberculosis and on ATT for 6 months. Then he developed second attack of CVA 8 months back for which he took some herbal medication for 3 months and rec...
Read more

case 19 - 58 year old male with right sided hemiplegia,acute hemorrhagic stroke ,hypertensive bleed in left frontoparietal lobe with midline shift to left

Image
    This is an 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 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: 58 year old male,daily labourer by occupation came with  c/o inability to move right upper and lower limb since yesterday evening  Aphasia since yesterday evening  Deviation of mouth to left side  Altered sensorium + History of present illness: Patient was apparently asymptomatic till yesterday evening and was brought home by outside people around 6pm where there was a sudden history of fall with inability to lift r...
Read more