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.



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