General medicine case-4

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A 65 years old man ,mason by occupation came to the casuality with weakness of left lower and upper limb since 1 month.

History of present illness:-

-Patient was apparently asymptomatic 1 month back ,then he developed weakness of left lower and upper limbs.

-Patient had similar weakness in December 2020  ,while he was having his breakfast ,he said that he was unable to lift the glass of water and unable to stand up from the chair.

-Patient took medication  for that and again he developed weakness since 1 month .

-Patient was unable to stand up from chair without a support ,unable to walk without stressing other limb.

-Patient complains stiffness and pain in his left lower limb.

Past history :-

-Patient has hypertension since 2 years and on regular medication.

-No history of diabetes mellitus, asthama, epilepsy,past surgery ,blood transfusion.

Family history :-

-No history of similar complaints in family .

Personal history:-

-Diet :- mixed.                                                          -Sleep :- Adequate 

-Appetite :- normal  

-Bowel and bladder movements- regular 

-Addictions - Alcohol since 40 years,drinks regularly 90 -180 ml whisky , stopped drinking 1 yr back .

        Smoking 1 pack of beedi /day since 40 yrs ,stopped smoking from 3 yrs .

General Examination :-

-Patient is conscious , coherent , cooperative and well oriented to surroundings.

- moderately built and nourished .

-No pallor , icterus ,cyanosis ,clubbing ,lymadenopathy.

Vitals :-

-Temparature -Afebrile 

-PR :- 65 beats /min 

RR :- 15 cycles /min 

BP :- 130/80 mmHg 

Spo2 :- 98%

GRBS :- 115 mg /dl 

Systemic Examination:-

-CVS :- chest wall is bilaterally symmetrical .

 S1,S2 heard , no murmurs 

-Respiratory system - bilateral air entry normal.

Central Nervous System :- 

-Patient is conscious ,oriented to time ,place and person .

-Hypotonia in left lower limb ,sensation decreased in left lower limb .

-Patient has hemiparetic gait.

Investigations :-

Fever chart 

X ray :- 

 

 

ECG:- 

 Renal  function tests:- 

Serum creatinine :- 0.8 mg /dl 

Urea :- 22 mg / dl 

Sodium :-138 meq /l 

Potassium :-3.7 meq /l 

Chlorine :- 94 meq /l 

Liver function tests :- 

Total bilirubin: 0.70 mg/dl 

Direct bilirubin: 0.20 mg/dl 

AST: 14 IU/l 

ALT: 19 IU/l 

ALP: 108 IU/l 

Total protein: 7.2 gm/dl 

Albumin: 4.3 gm/dl 

A/G: 1.48

Urinary electrolytes :- 

Na - 302

K - 33.6

Cl - 442

Provisional diagnosis:- 

Peripheral neuropathy ,left hemiparesis .

Treatment :- 

SOAP NOTES 

SUBJECTIVE 

Weakness of Left UL & LL 

Dragging pain in left lower limb 

OBJECTIVE : 

Temperature - Afebrile 

BP - 100/70 mm hg 

PR - 66 bpm 

RR - 15 cpm 

SPO2 - 98% at RA 

ASSESSMENT :-

Peripheral neuropathy 

K/C/O LEFT HEMIPARESIS

PLAN OF CARE: 

1. Inj OPTINEURON 1 amp in 100 ml NS slowly IV/BD 

2. Tab ECOSPIRIN - AV 75mg/20 mg PO/OD 

3. Tab TELMA 40mg PO/OD 

4. Tab PREGABA -M 75 mg PO/HS 

5. Physiotherapy of Left UL & LL