45 M L lower limb weakness

 

A 45YR OLD MALE TRACTOR DRIVER CAME TO THE OPD WITH CHIEF COMPLAINTS OF LEFT LOWER LIMB WEAKNESS.






AMC BED 2


45yr old male, Tractor driver by occupation ,came to the OPD with chief complaints of 
LEFT LOWER LIMB WEAKNESS since 5 days.
 Weakness only from knee to foot.
Acute in onset.
No any progression in weakness.
No H/O vomitings fever, diarrhoea
NO H/O slurring of speech
               Giddiness
               Normal bowel and bladder movements.
 No any sensory symptoms, tingling, numbness

        On last Saturday  night at 12:00AM , he had his dinner , walked into his room and slept ,all by himself. Later after that he wanted to go to washroom, he was NOT ABLE TO LIFT HIS LEFT LOWER LIMB ,if he tries to stand, he was falling off.

PTCA 3YRS BACK.

NOT A K/C/O DM,HTN, ASTHMA, TB, EPILEPSY.

NO significant family history
No significant drug history.


PERSONAL HISTORY:
Takes mixed diet
Appetite is normal
Regular bowel and bladder movements
Adequate sleep
Alcohol, smoking occasionally.

O/E
pt is C/C/C
NO pallor icterus, cyanosis,clubbing, lymphadenopathy, edema.
Afebrile temperature
PR:70 bpm
BP:100/60mmhg
RR:18cpm
SPO2:99%
GRBS:350MG/DL , UNCONTROLLABLE SUGARS.

CVS: S1S2+
PER ABDOMEN: SOFT
RS: BAE+

CNS:
-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
TC:13100
PL:2.89

RBS:382MG/DL

LFT:
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

Sugar trends 





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:
DIAGNOSIS :: MULTIPLE ACUTE INFRACT IN RIGHT OCCIPITAL AND FRONTOPARIETAL LOBES WITH DENOVO T2DM 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

PLAN FOR DISCHARGE 



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