Case 2

 weakness of Rt upper and lower limbs 

July 3 2023

 

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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 G.Manisha

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 

DAILY ROUTINE- 

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 

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