62 year old female patient unable to move left upper and lower limb and Backpain

62yr old female patient with complaints of Unable to move her left upper and lower limb and Backpain
November 7, 2021

Vasanthi Reddy L.
4th year MBBS

 This is an online elog book to discuss our patient's deidentified health data shared after taking her or guardian's signed informed consent. Here we discuss our individual patient 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 Elog also reflects my patient centre's online learning portfolio and valuable inputs on the comment box is welcome. 

CASE :

A 62yr old female patient came to gm opd with a chief complaints of 
-Unable to move her left upper and lower limb since four days and
-Backpain since four days


HISTORY OF PRESENTING ILLNESS-

Patient is apparently asymptomatic 1yr back and she developed weakness in her left upper and lower limbs for which she took help of stick to walk and work,

Suddenly four days back in early morning she is unable to get up from bed,

She is unable to move her left upper and lower limb completely since four days,

It is associated with back pain since 4days and involuntary micturation and defecation is present,

No h/o fever, vomiting, headache, deviation of mouth and no slurring of speech.


History of past illness-

She is known case of DM and HTN,
No h/o TB,Asthma,CAD, Epilepsy,
No h/o surgery and trauma.

TREATMENT HISTORY-

no treatment is taken for DM and HTN.

FAMILY HISTORY-  Not significant.

PERSONAL HISTORY-

she is married
Appetite- decreased
Diet- mixed
Sleep- decreased
Bowel- regular
Bladder- involuntary micturation
Addictions- occasional alcoholic
Allergies- no 

GENERAL EXAMINATION-

Patient is examined with an informed consent in an well illuminated room,
Patient is conscious, coherent and cooperative,well orientated to place,time and day.
Pallor- no,
Icterus- no,
Cyanosis- no,
Clubbing- no,
Lymphadenopathy- no,
Edema- no,
Dehydration- no.

VITALS-
TEMP- afebrile
PR- 88bpm
RR- 19/min
BP- 130/90mmofHg
SpO2-98%

SYSTEMIC EXAMINATION
CVS:-
Thrills- no
Cardiac sounds- S1 S2 present
Cardiac murmurs - no 

RESPIRATORY SYSTEM:-
Dyspnea- no 
Wheeze- no
Position of trachea- central
Breath sounds- vesicular

ABDOMEN:-
Shape of the abdomen- obese
Tenderness - not
Palpable mass - no
Hernial orifice - normal
Free fluid - no 
Bruits - no
Liver not palpable
Spleen not palpable

CNS EXAMINATION:-
Level of consciousness - alert
Speech - normal
Neck stiffness - no
Kernig's - no
Higher mental functions - intact
                                  R                   L     
Power :-  UL            4/5               0/5
                LL             4/5               0/5

Tone :-     UL           Normal        decreased 
                 LL           Normal        decreased
       
          B        T         K         A               P
R       +         +         +         +        increased    
L        -          -          -           -        increased

Cerebral signs:-
Finger-nose in-coordination :- no 
Knee-heel in-coordination :- no


INVESTIGATIONS:-
Blood: 
Hb :- 11.4g/dl
RBC :- 2.45 million cells/cu mm
Platelet :- 4.10 lakh /cu mm 
A/G  :-  1.61

ECG: 
USG:

MRI :

PROVISIONAL DIAGNOSIS :-
left sided hemiplegia?
Right MCA stroke. 


TREATMENT:-
1) IVF - 2NS , 1RL @ 100ml/hr
2) Inj. Thiamine 1 amp. In 100ml NS IV/OD
3) Inj. Optineuron 1amp in 100ml NS IV/OD
4) Tab. Atorvas 40mg PO OD H/S
5) Tab pregabalin 75mg PO OD H/S
6) Tab. PAN 40mg. PO. OD 
7) GRBS charting every 6th hourly 
8) Tab. Ecospirin 150mg/PO/OD
9) Tab. Clopidogrel 75mg/ PO/OD
10) Foley's catheterization

BP , pulse rate, spo2 check every 4th hourly .




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