1802102016 final practical -long case

 This is an online e log book to discuss our patient de-identified health data shared after taking his /her /guardians signed informed consent.Here we discuss our individual patients problem through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evidence based input.

A 65 yrs old male patient agriculture by occupation came to OPD with the complaint of right sided weakness both upper and lower limbs since 3 days .

History of present illness:- 

-Patient was apparently normal 3 days back .

- Patient while doing some work he not able to lift his right hand . 

- Patient then after his work ,while he was eating breakfast he was not able to mix the food .

-Patient then went to local Rmp and took some injection  and went home with a hope of recovery .

-Patient next morning  developed weakness of his right lower limb then he came to our hospital .

-No deviation of tongue and angle of mouth ,no drooping of eyelid .

Past history:- 

No history of similar complaints in the past .

No history of diabetes , hypertension, TB ,CAD ,CVD ,Asthma .

Family history :- 

No history of similar complaints in the family members.

Personal history:- 

Diet :- mixed 

Appetite :- normal 

Sleep :-normal 

Bowel and bladder movements:- normal 

Addictions :- History of smoking (beedi) since 55yrs ,alcohol since 45yrs .

Drug history :- 

Patient is not allergic to any drugs, he was not on any medications .

General examination :- 

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

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

Vitals :- 

Temparature:-Afebrile 

Pulse rate :- 83 beats/min 

Respiratory rate :- 20 cycles/ min 

Blood pressure :- 110/80 mmHg 

SpO2 :- 98% 

Systemic examination :- 

 CVS :- S1,S2 heard ,no murmurs .

RS :- Bilateral air entry normal .

CNS :- HMF :- intact 

Power   RT      LT

UL          2/5    4/5

LL           3/5    4/5

Tone         RT    LT

UL  Decreased   Normal

LL  Decreased.  Normal

Reflexes       RT            LT

     Biceps.       -                -

    Triceps.      -                -

 Supinator      -              -

         Knee.      -               -

        Ankle       -               -

Cerebellar :- finger -nose in coordination -no 

Heel -knee in coordination -no

Abdomen :-palpation ,auscultation :- soft ,nontender .

https://youtu.be/dEZY7nBFzvY

Provisional diagnosis :-CVA with heart failure with reduced ejection fraction .

Treatment :-  

T.Ecospirin 150mg PO/OD

T.Clopidogrel 150mg PO/OD

T.Atorvastatin 40mg PO/OD

T.lasix 20mg PO/OD 

T.Ramipril 2.5 mg PO/OD 

T.Cardivas 3.125 mg PO/OD 

Inj.Optineuron IV in 100ml NS/IV stat

GRBS monitoring 4th hourly

Physiotherapy of Right Upper limb and lower limb