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 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 Harika Madala

July 1,2023

A 55 year old male patient, 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 





FAMILY 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- 92 bpm
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

Central Nervous System 

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
MCV                       83.6
MCH                      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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