52 year old with numbness in both upper and lower limbs since 4 hrs

 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 available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome.



 Pt came with complaints of 

Tingling and numbness in right upper limb and lower limb since 4 hours

Weakness in right upper limb and lower limbs since 2 hours

Difficulty in walking


HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 4 hours ago. 

Then he developed tingling and numbness in right upper and lower limbs since 4 hours 

Weakness in right UL and LL since two hours and difficulty in walking.

No H/O loss of consciousness, involuntary movements,giddiness, vomitings, pain abdomen, loose stools

No H/O involuntary micturition or defecation .


PAST HISTORY:

K/c/o CVA with right hemiparesis two years ago-on medication since then

K/c/o HTN -on tab.telma 40mg PO/OD

Not k/c/o DM,asthma,thyroid disorders,epilepsy,CAD 


PERSONAL HISTORY:

Diet-mixed 

Appetite:normal 

Bowel and bladder movements -regular 

Addictions-alcohol:occasionally 

Sleep -adequate


FAMILY HISTORY:

not significant 


GENERAL EXAMINATION:

Patient was consious, coherrent and co-operative. Well oriented to time place and person.moderately  built and nourished 
No pallor 
No icterus 
No clubbing
No cynosis
No generalized lymphadenopathy 
No b/L pedal edema




Vitals
Pulse-74bpm
BP 180/100mmhg
Respiratory rate-18cpm
Spo2-99%
Temp-afebrile 
GRBS:148 mg%


Systemic Examination -
CVS : 
S1 S2 present
No murmurs

RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard

ABDOMEN:
Shape of abdomen: round
Soft, non tender.
No rigidity or guarding.
BS+

CNS :
E4M5V6 - 15/15
Cranial nerves-intact,normal 
Motor system -
                                   Right.         Left 
           Tone.         UL. N.            N
                               LL   N              N

            
           POWER.   UL  4/5          5/5
                               LL   4/5         5/5 

Reflexes: 
                              Right             Left

Biceps                     2+                 2+
Triceps                   2+                  2+
Supinator               1+                  1+
Knee                        2+                  2+
Ankle                       1+                   1+

Plantars- B/L extensors 

Gait-hemiplegic gait 

INVESTIGATIONS: 
ECG:



MRI BRAIN: 








Blood urea: 47mg/dl

Serum creat :1.3mg/dl








Provisional diagnosis:

  Recurrent CVA with acute ischemic stroke with acute infract in left internal capsule and corona radiata with HTN (2yrs)


Treatment:

1 tab ecosprin 75 mg+clopidogrel 150 mg+atorvastatin 20 mg po/hs

2.tab.PREGABA-M 75/10 PO/OD

3.tab.cinod 40mg PO/BD

4.physiotherapy of rt upper and lower limb

5.monitor vitals and inform sos



13-07-23


S:

Tingling and numbness decreased

Stools passed 

No fever spikes 


O:

Patient is c/c/c 

Temp: 98.4 F

PR- 84 bpm

RR-18 cpm 

BP-140/90 mm of Hg

Spo2 -98% 


CNS: 

GCS- E4 V5 M6

Pupils: NSRL

Power - 

      Rt     Lt

UL 4/5   5/5   

LL 4/5   5/5   


Tone-   Rt.       Lt

UL         N         N

LL       Hyper   Hyper 

Reflexes

                  Rt          Lt

B -              2+.       2+

T -               2+.      2+

S.                 1+.       1+

K -               2+.      2+

A -               1+        1+

Plantar  extensor  extensor 

Circumduction gait 


RS-B/L air entry present, NVBS

CVS- S1S2present, no murmurs heard


A:

  Recurrent CVA with acute ischemic stroke with acute infract in left internal capsule and corona radiata with HTN (2yrs)


P:

1 tab ecosprin 75 mg+clopidogrel 150 mg+atorvastatin 20 mg po/hs

2.tab.PREGABA-M 75/10 PO/OD

3.tab.cinod 40mg PO/BD

4.physiotherapy of rt upper and lower limb

5.monitor vitals and inform sos



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