Case history 07

Case history 07:

 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 patient's 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 the comment"

A 45 year old male tractor driver by occupation came to OPD with chief complaints of weakness of lower limb.

HISTORY OF PRESENT ILLNESS:
Patient was asymptomatic 5 days back,  where his daily routine comprises of waking up early in the morning at 6 '0 clock , having breakfast ( idli, dosa or rice), reaching the farm field at 9 '0 clock,  where he used to drive tractor to pull equipments of ploughing, harvesting  of crops and having lunch ( rice, dal), winding up the work by 6 in the evening, reaching home and completing dinner by 9 ( chapati and veg curry)
 On one fine day, he came to home and have dinner , walked into his room and slept.
 At 12' 0 clock in the mid night, patient wanted to go to washroom but he was unable to LIFT HIS LEFT LEG and was unable to stand by himself. If he  tries to stand, he was falling off.

He was rushed to local hospital where he was advised to KIMS.

Patient complains of weakness acute in onset of left lower limb only from knee to foot which gradually   progresses to left hand. He was unable to lift his left hand the next evening.

No history of fever, headache and vomiting

No history of slurring of speech, giddiness
 
No history of tingling and numbness.


HISTORY OF PAST ILLNESS:
 
 4 years ago, at 12 'o clock in afternoon, patient was sitting in home, watching t.v, a sudden onset of pain appears which is severe throbbing type near chest region.
He went to RMP doctor where he suggested to go to hyderabad for treatment.
There he underwent PTCA( Percutaneous transluminal coronary angioplasty)  and undergone 3 weeks of treatment .
 
Not a known case of diabetes, hypertension asthma and COPD

PERSONAL HISTORY:

Diet : mixed
Appetite: normal
Regular bowel and bladder habits
Sleep: adequate
 Patients is chronic alcoholic since 15 years. He used to drink 4, 5 times a weak ( 1 peg at each sitting) and he smokes occasionally. 

Treatment history:
 He underwent PTCA 4 yrs back.

GENERAL EXAMINATION:
 Patient is conscious, coherent and cooperative and well oriented to time, place and person.
NO pallor, icterus, jaundice , cyanosis.
 There is no edema and generalised lymphadenopathy. 

Vitals:
     Temp : afebrile
      PR : 70bpm
       Bp: 100/ 60 mmhg
       RR: 18cpm
       Spo2: 99%
        GRBS : 350mg / dl ( UNCONTROLLABLE SUGARS) 
 
SYSTEMIC EXAMINATION:
 
 CVS:

Chest wall is bilaterally symmetrical.

No precordial bulge

AUSCULTATION: S1 and S2 sounds are heard

RESPIRATORY SYSTEM:

Postion of trachea - central

Bilateral air entry- positive

PER ABDOMEN:

Abdomen is soft and mild tenderness is seen in epigastric and right hypochondral region.

Bowel sounds heard

free fluid is seen.

CENTRAL NERVOUS SYSTEM:

-POWER OF ALL LIMBS 5/5 ,
 
EXCEPT LEFT LOWER LIMB: 3/5

-REFLEXES OF LEFT LOWER LIMB ABSENT

-PLANTARS - FLEXORS.

TONE OF LEFT LL: HYPOTONIA.

SENSORY:

PROPRIOCEPTION : INTACT

FINE TOUCH   +
CRUDE TOUCH.  +
PRESSURE   +
PAIN +
TEMP +
VIBRATION+
POSITION+
Cranial nerves: intact
















INVESTIGATIONS:

HEMOGRAM:
       HB:13.6
         TLC:13100
           PL:2.89

RBS:382MG/DL

LIVER FUNCTION TEST:
 
TB:1.24
DB:0.64
AST: 18
ALT: 10
ALP: 168
TP: 6.8
ALB: 3.2
A/G: 0.92

SERUM ELECTROLYTES:
           Na: 135
            K: 4.7
             Cl: 96

S . CREATININE: 0.9 MG/DL
BLOOD UREA : 45

CUE:
SUGAR :++++
ALB: NIL
PUS CELLS: 3-6
EPI CELLS: 2-4.

PROVISIONAL DIAGNOSIS:

PTCA 3YRS BACK

CVA L/L MONOPARESIS
?FRONTAL LOBE INFARCT RIGHT SIDE.
? UNCONTROLLED DENOVO DM 2

PLAN OF CARE:
1.inj.OPTINEURON 1AMP in 100ml NS/IV/OD
2.T. PAN 40MG PO/OD
3.inj.HAI s/c / TID
4.GRBS CHARTING 7 O PROFILE
5.monitor BP,PR,RR. 

2/11/21:
SOAP NOTES
 Unit 1 case
 AMC bed 2
 45/M
 Day -1
 S: 
 C/o weekness of left lower limb reduced
 
O: 
Pt is c/c/c
BP: 110/70 mmHg
PR: 80bpm
CVS: S1S2+
RS: BAE+
P/A: SOFT & NON TENDER
CNS: HMF INTACT
I/O: 1700/800 ML
GRBS@7:00 AM - 222 MG/DL

A: 
LEFT LOWER LIMB MONOPARESIS SECONDARY TO ?CVA ? FRONTAL LOBE INFARCT / BLEED ? DENOVO DIABETES .POST PTCA. 

P:
INJ. OPTINEURON 1 amp in 100ml NS/IV/OD
T. PAN 40 MG PO/OD
T. ECOSPRIN - 75 MG PO / OD
T. ATORVAS - 40 MG PO / OD
T. CLOPIDOGREL - 75 MG /PO / OD
INJ. HAI 8 - 16 - 8
INJ.NPH 12- X - 12

3/11/21:
SOAP NOTES
45/M
UNIT 1 CASE
PT SHIFTED TO WARD

S:
NO FRESH COMPLAINTS

O:
Pt is c/c/c
BP: 120/80 mmHg
PR: 88bp
RR: 18 CPM
CVS: S1S2+
RS: BAE+
P/A: SOFT & NON TENDER
CNS: HMF INTACT
Gait : scissors gait
TONE:    rt.      Lt
               N.       Decreased
               N.       Decreased
 Power: 3/5       1/5
              3/5.      1/5
Reflexes: B.  T.   S.  A.  K.  P. 
          RT: 2+. 2+ 2+ -   -.  F-PLANTAR
          LT: 2+.  2+ 2+ -.  -.  F-PLANTAR
PUPILS: B/L  NSRL    
HAND GRIP : RT.    LT
                       99%.  40%     
GRBS: 170 MG/DL 
I/O - 1800/1600 ML

A:
LEFT LOWER LIMB MONOPARESIS SECONDARY TO ?CVA ? FRONTAL LOBE INFARCT / BLEED ? DENOVO DIABETES .POST PTCA 3 YEARS BACK

P:

INJ. OPTINEURON 1 amp in 100ml NS/IV/OD
T. PAN 40 MG PO/OD
T. ECOSPRIN - 75 MG PO / OD
T. ATORVAS - 40 MG PO / OD
T. CLOPIDOGREL - 75 MG /PO / OD
INJ. HAI 10 - 16 - 12
INJ.NPH 12- X - 12
PHYSIOTHERAPY FOR LEFT UL & LL



4/11/21:
SOAP NOTES
45/M
UNIT 1 CASE
In WARD

S:
NO FRESH COMPLAINTS

O:
Pt is c/c/c
BP: 130/80 mmHg
PR: 85bp
RR: 20CPM
CVS: S1S2+
RS: BAE+
P/A: SOFT & NON TENDER
CNS: HMF INTACT
Gait : scissors gait
TONE:    rt.      Lt
               N.       Decreased
               N.       Decreased
 Power: 3/5       2/5
              3/5.      2/5
Reflexes: B.  T.   S.  A.  K.  P. 
          RT: 2+. 2+ 2+ -   -.  F-PLANTAR
          LT: 2+.  2+ 2+ -.  -.  F-PLANTAR
PUPILS: B/L  NSRL    
HAND GRIP : RT.    LT
                       99%.  50%  
   GRBS: 8am 135MG/DL 
Insulin --hai 10units +nph 12 units 


A:
DIAGNOSIS :: MULTIPLE ACUTE INFRACT IN RIGHT OCCIPITAL AND FRONTOPARIETAL LOBES WITH DENOVO T2DM WITH POST PTCA 3YRS BACK

 

P:

INJ. OPTINEURON 1 amp in 100ml NS/IV/OD
T. PAN 40 MG PO/OD
T. ECOSPRIN - 75 MG PO / OD
T. ATORVAS - 40 MG PO / OD H/S
T. CLOPIDOGREL - 75 MG /PO / OD
INJ. HAI 10 - 16 - 12
INJ.NPH 12- X - 12
PHYSIOTHERAPY FOR LEFT UL & LL 


5/11/21:
SOAP NOTES
45/M
UNIT 1 CASE
In WARD

S:
NO FRESH COMPLAINTS

O:
Pt is c/c/c
BP: 120/80 mmHg
PR: 88bp
RR: 20CPM
CVS: S1S2+
RS: BAE+
P/A: SOFT & NON TENDER
CNS: HMF INTACT
Gait : scissors gait
TONE:    rt.      Lt
               N.       Decreased
               N.       Decreased
 Power: 3/5       2/5
              3/5.      2/5
Reflexes: B.  T.   S.  A.  K.  P. 
          RT: 2+. 2+ 2+ -   -.  F-PLANTAR
          LT: 2+.  2+ 2+ -.  -.  F-PLANTAR
PUPILS: B/L  NSRL    
HAND GRIP : RT.    LT
                       99%.  50%     
GRBS: 8am 133MG/DL 
Insulin --hai 10units +nph 12 units 

3/11/21 8pm 120mg/dl 
A:
 FINAL DIAGNOSIS :: MULTIPLE ACUTE INFARCT IN RIGHT OCCIPITAL AND FRONTOPARIETAL LOBES WITH DENOVO TYPE 2 DM WITH POST PTCA 3YRS BACK.

 

P:

Tab MVT PO/OD 
T. PAN 40 MG PO/OD
T. ECOSPRIN - 75 MG PO / OD
T. ATORVAS - 40 MG PO / OD H/S
T. CLOPIDOGREL - 75 MG /PO / OD
INJ. HAI 10 - 16 - 12
INJ.NPH 12- X - 12
PHYSIOTHERAPY FOR LEFT UL & LL





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