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A 55Y M with tingling sensation and weakness of Rt upper and lower limbs

A 55Y M with tingling sensation and weakness of Rt upper and lower limbs

 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. 

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.                                                                                     

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 diagnosis and treatment plan


Blog by chetan.B

July/1/23

A 55 year old male patient who is a resident of Tirumalagiri came with 


CHIEF COMPLAINTS-
1. Tingling sensation in Rt upper and lower limbs since yesterday 
2. Weakness in the Rt upper and lower limbs since yesterday 

HISTORY OF PRESENTING ILLNESS-
Pt was apparently asymptomatic before yesterday afternoon then he developed weakness of Rt upper and lower limbs which is insidious in onse, gradually progressive
Weakness is associated with tingling sensation
 
No c/o deviation of mouth , loss of consciousness, headache, giddiness, vomitings, Pain
 
No H/o involuntary passage of urine or stools 
No H/o fever , loose stools , sob , pain abdomen
 
Slipping of chappals present while walking 
Decreased hearing in both the ears since 10 years 
PAST HISTORY- 
Pt is a k/c/o HTN since 4-5 months,  used medication for 2 months then stopped ( unknown medication) 
Not a k/c/o DM , TB , EPILEPSY, CVA , CAD, THYROID DISORDER, ASTHMA 


PERSONAL HISTORY- 

Diet - mixed 

Appetite - normal 

Bowel and bladder- regular 

Sleep - adequate 

Was an alcoholic since 15 years stopped taking 6 months back 

Was smoker since 20 years stopped 6 months back 

Was smoker since 20 years stopped 6 months back 





FAMILIES HISTORY-

Not significant


GENERAL EXAMINATION- 

Pt was conscious, coherent and cooperative 

Moderately built and nourished 

No pallor,  icterus , clubbing, cyanosis, lymphadenopathy, Edema 


VITALS- 

Temperature- Afebrile 

BP- 110/80 mmHg 

PR- 92bpm

RR- 18 cpm


SYSTEMIC EXAMINATION

ABDOMEN EXAMINATION

INSPECTION- 

Shape - round large with no distension 

Umbilicus - inverted 

Equal symmetrical movements in all quadrants with respiration 

No visible pulsations , palpations , dilated veins or localised swelling

PALPITATION - 

No local rise of temperature 

No tenderness 

No organometaly 

PERCUSSION- liver dullness heard at 5th intercostal space 

AUSCULTATION- 

Bowel sounds present 

No bruit heard 


Cardiovascular system  

JVP - not raised 
Visible pulsations: absent 
Apical impulse : left 5th intercostal space in midclavicular line.
Thrills -absent 
S1, S2 - heart sounds heard 
Pericardial rub - absent

Respiratory System- 

Patient examined in sitting position
Inspection:-
oral cavity- Normal ,nose- normal ,pharynx-normal 
Shape of chest - normal
Chest movements : bilaterally symmetrical
Trachea is central in position.
Palpation:-
All inspiratory findings are confirmed
Trachea central in position
Apical impulse in left 5th ICS, 
Chest movements bilaterally symmetrical 
AUSCULTATION 
BAE+,  NVBS


CNS:-

HMF- 
Pt is conscious 
Speech- normal        


                              Right       Left

Spinothalmic

1. Crude touch-    +             +

2. Pain-                  +             +

3.Temperature-     +             +


Posterior Coloumn

1. Fine touch          +             +

2.Vibration             Felt         Felt

( over bony prominence ) 

                               

MOTOR EXAMINATION 

Tone  

UL-                        Increased            N

LL-                         Increased            N


Power 

UL-                       4/5        5/5

LL-                       4/5         5/5


Reflexs               

B                           +2          +2

T                           +1          +2

S                            -            -

K                           +1           +2 

A                            -            +2

Plantars            Mute            Flexor



PROVISIONAL DIAGNOSIS- 

Acute CVA with Rt Hemiparesis 

?. Stroke 

INVESTIGATIONS- 

LIVER FUNCTION TEST (LFT)


Total Bilurubin Result   0.86

Direct Bilurubin  0.14

SGOT(AST).  32

SGPT(ALT).   27

ALKALINE PHOSPHATE   100

TOTAL PROTEINS  #6.3

ALBUMIN.  4.1

A/G ratio   1.94


SERUM ELECTROLYTES

SODIUM.   141Units mEg/L

POTASSIUM.   4.0mEGIL

CHLORIDE.   103mEg/L

CALCIUM IONIZED  1.27


Serum Creatinine.  1.2mg/dl


RBS.    90mg/dl.


Blood Urea.    26mg/dl



HEMOGRAM

HAEMO GLOBIN    15.6

TOTAL COUNT       9,400   

NEUTROPHILS      54

LYMPHOCYTES.    38

EOSINOPHILS.      01

MONOCYTES.       07

BASOPHILS.          00

PCV.                       43.7

M CV.                     83.6

MC H.                     29.8

MCHC.                   35.7

PLATELET COUNT  2.82L

RBC COUNT.         5.32


COMPLETE URINE EXAMINATION 

APPEARANCE.    Pale yellow  

REACTION.          Clear

SP.GRAVITY.        1.010

ALBUMIN.             Nil

SUGAR.                Nil

BILE SALTS.         Nil

BILE PIGMENTS. Nil

PUS CELLS.         2-3

EPITHELIAL CELLS.      2-3           

RED BLOOD CELLS.     Nil

CRYSTALS.         Nil

CASTS.                Nil

AMORPHOUS.    Absent 

DEPOSITS

OTHERS.            Nil

ECG - 




TREATMENT- 

1. ECOSPRIN 75mg + Atorvastatin 20mg PO/HS

2  tab MVT PO/OD


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