50 year old male with weakness in left upper and lower limb

 50 year old male with weakness in left upper and lower limb

June 02, 2023

 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 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-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 .



 A 50yrs old  who is a resident of cheruvugattu came with c/o weakness in  left UL and LL since today morning(05/05/23)At 8:00AM


HOPI-

patient was apparently asymptomatic till today morning and attenders noticed that he couldn't get up from bed and complained of weakness in left UL and LL which is of sudden onset and gardually progressive.


-No h/o loss of consciousness, involuntary movements, drooling of saliva, involuntary micturation and defeacation.


 Daily routine- patient wakes up at 6:00Am in the morning and freshens up and to heis sister in law for breakfast and tea and returns home ,watches Tv and have lunch at 12:30PM and sleep in the afternoon and have tea at5:00 Pm and have dinner at 8:00pm.



Past history-

K/C/O Acute CVA (Rt.hemiparesis) 2yrs back.

 -1yr back  came to OPD with c/o urinary incontinence ,drooling of saliva.

 Took medication and left.

 K/C/O  HTN and DM since 2yrs and  on regular medication.

T.metformin 500mg + glimperide 1mg Po/od (mrng)

T.Amlong 2.5mg po/od



PERSONAL HISTORY:

Diet- mixed

Appetite - normal

Sleep -normal

Bowel and bladder -regular

Addictions-

-He is chronic alcoholic since 30 years, stopped 2 years  after  right hemiplegia.

-he chews tobacco since 10 years .


FAMILY HISTORY:

No similar complaints in the family.


TREATMENT HISTORY:

He is on antihypertensives and metformin


GENERAL EXAMINATION:- 

GCS -E4V4M5


-B/L pupils-NSRL


Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 













Vitals :- 

Temp - 97.2F

BP - 110/70 mm Hg

Pulse rate - 72 bpm

Respiratory rate - 14 cycles per minute 


SYSTEMIC EXAMINATION:

 CNS EXAMINATION :-

Motor system

Power:-


Rt UL - 3/5 Lt UL-0/5 


Rt LL - 3/5  Lt LL-0/5


Tone:-


Rt UL - Hyper


Lt LL-Hypo


Rt LL-Hyper


Lt LL- Hypo




Reflexes: 


                   Right                    Left


Biceps:      ++                    +++


Triceps:       ++                  +++


Supinator:  +++                    ++


Knee:         +++                    ++


Ankle:            +                   +



Plantar:      flexor.         Extensor


Involuntary movements - absent


Fasciculations - absent




Sensory system - 


-Pain, temperature, crude touch, pressure sensations,Fine touch, vibration, proprioception -normal


Cerebellum - 


Finger nose test , dysdiadochokinesia, Rhomberg test could not elicited.




Autonomic nervous system - normal

• Meningeal sign  

Neck stiffeness -present 

Brudzinski sign -present

Kernigs sign -present.

ABDOMEN EXAMINATION:


Inspection -


Umbilicus - inverted


All quadrants moving equally with respiration


No scars, sinuses and engorged veins , visible


 pulsations.


CVS EXAMINATION 


S1S2 heard,no murmurs.


Respiratory system examination


Bilateral air entry present.


Investigations-


ECG













2D echo


Mild TR with PAH;Mild AR;No MR


No RWMA No AS/MS,sclerotic AV


Good LV systolic function


Diastolic dysfunction ,no PE. 


Review 2d echo


Doppler impression-


Raised CIMT in b/l CCA's


b/l CCA and ICA show normal biphasic  wave pattern,calibre and colour uptake


No e/o plaques in b/l CCA'S and ICA'S.




Lumbar puncture done on 06/05/23 at 8:30pm





INVESTIGATIONS






Diagnosis-


Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus 


K/c/o Right hemiparesis in 2020.


K/c/o HTN and Type 2 DM since 2yrs.






Treatment


1.RT Feeds 


-50ml water every 2nd hrly


-200ml Milk+ 2spoons protein powder every 4th hrly.


2.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.


3.inj.optineuron 1amp in 100ml NS IV/OD.


4.T.Ecospirin-AV 75/10


RT/OD.


5.T.Amlong 5mg RT/OD.


6.Monitor BP,PR,RR,Spo2,Temp


7.GRBS 7 profile


8.physiotheraphy


9.Frequent position change 2nd hrly.


Follow up -06/05/23


GCS-E4V3M5


Vitals :- 

Temp - 97.2F

BP - 130/80 mm Hg

Pulse rate - 90bpm

Respiratory rate - 20 cycles per minute


Motor system

Power:-


Rt UL - 3/5 Lt UL-0/5


Rt LL - 3/5  Lt LL-0/5


Tone:-


Rt UL - Hyper


Lt LL-Hypo


Rt LL-Hyper


Lt LL- Hypo




Reflexes: 


                   Right                    Left


Biceps:      ++                    +++


Triceps:       ++                  +++


Supinator:  +++                    ++


Knee:         +++                    ++


Ankle:            +                   +




Plantar:      flexor.         Extensor


07/05/23-


GCS-E3V3M5


S    +      +




K ++     ++




A   +    +




P  Flexor   Extensor




Tone:


         Rt      Lt


UL.  Hyper hyper


        Hyper hyper


Power:


         Rt.         Lt


UL.    3/5.      2/5


 L  L    0/5.     0/5


A: 


Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus 


K/c/o Right hemiparesis in 2020.


K/c/o HTN and Type 2 DM since 2yrs.


-stool not passed


P: 


1.RT Feeds 


-100ml water every 2nd hrly


-200ml Milk+ 2spoons protein powder every 4th hrly.


2.Inj.Piptaz 4.5gm IV TID


3.Inj.Clindamycin 600 mg IV TID


4.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.


5.inj.optineuron 1amp in 100ml NS IV/OD.


6.T.Ecospirin-AV 75/10


RT/OD.


7.T.Amlong 5mg RT/OD.


8.Monitor BP,PR,RR,Spo2,Temp


9.GRBS 7 profile


10.IVF - 2NS @75ml/hr


10.physiotheraphy


11.nebulisation - ipravent 2nd hrly,mucomist 2nd hrly,budecort-4th hrly.


12.Frequent position change 2nd .hrly


13.syp.LACTULOSE 15ml/RT/HS.

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