A 55 year old male 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

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