A 55 year old male with tingling sensation and weakness in right upper and lower limbs

Hello, I am Harshitha Shalini , a 5th semester medical student.  This is an online elog book to discuss our patients health data after taking his/her consent. This also reflects my patient centered online learning portfolio.

A 55 year old male patient R/O Thirumalagiri came to OPD 
CHIEF COMPLAINTS-
1. Tingling sensation in Right upper and lower limbs since 4 days
2. Weakness in the Right upper and lower limbs since 4 days

HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 4 days back. Then he developed weakness of Right upper and lower limbs which is insidious in onset, gradually progressive.
Weakness is associated with tingling sensation which is improving 
 
No history of deviation of mouth , loss of consciousness, headache, giddiness, vomitings,fever,SOB, pain.
 No history of involuntary passage of urine or stools 
 Slipping of chappals is seen while walking.
Decreased hearing in both the ears since 10 years 

PAST HISTORY- 
Pt. is a k/c/o HTN since 4-5 months. He  used medication for 2 months and then stopped.
Not a k/c/o DM , TB , epilepsy, Coronary artery  disease, thyroid, asthma

PERSONAL HISTORY-
Normal appetite
Mixed diet
Regular bowel and bladder movements
Adequate sleep
He was an alcoholic since 15 years and  stopped taking 6 months back 
Known smoker since 20 years and  stop ooped 6 months back 

No significant FAMILY HISTORY

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 

Pulse Rate-  92bpm

Respiratory Rate - 18/min


SYSTEMIC EXAMINATION- 

ABDOMEN EXAMINATION- 

INSPECTION- 

Shape - round large with no distension 

Umbilicus - inverted 

Equal symmetrical movements in all quadrants with respiration 

No visible pulsations , palpitations , dilated veins or localised swelling

PALPATION- 

No local rise of temperature 

No tenderness

PERCUSSION-

 liver dullness heard at 5th intercostal space 

AUSCULTATION- 

Bowel sounds present


Cardiovascular system-   

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

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 inspectory  findings are confirmed
Trachea central in position
Apical impulse in left 5th Intercostal space
Chest movements bilaterally symmetrical 
Auscultation:-
Normal vesicular breath sounds


CNS:-
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 Cerebro vascular accident with Right Hemiparesis 


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


TREATMENT- 

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

2  tab MVT PO/OD

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