45 Year Old Male tractor driver, Left Lower Limb Weakness


110 Rachana Gangula 9th Sem  

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 came to the OPD with chief complaints of weaknesses in the left lower limb 

45yr old male, Tractor driver ,came to the OPD with chief complaints of 
LEFT LOWER LIMB WEAKNESS since yesterday.
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 or giddiness.
No H/O any sensory symptoms, tingling, numbness.

          Yesterday night, the patient went to bed following dinner and slept all by himself. He woke up at around 12:00 AM to use the washroom when he was not able to life his Left Lower Limb all of a sudden. 
Surgical History of 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.

ON EXAMINATION 

Patient is conscious, coherent, cooperative and well oriented to time and place.
NO pallor icterus, cyanosis, clubbing, lymphadenopathy, edema.





General Examination- 
PR:70 bpm
BP:100/60mmhg
RR:18cpm
SPO2:99%
GRBS:350MG/DL 

CVS: S1 S2+
PER ABDOMEN: SOFT
RS: BAE+

CNS:
TONE- RU - Normal 
             RL - Normal 
             LU- Normal 
             LL- HYPOTONIA

POWER- RU - 5/5
                RL - 5/5
                LU- 5/5
                LL- 3/5
REFLEXES-  B.  T.   S.   A.   K.   P. 
                RT: 2+. 2+  2+  -     -.     F-PLANTAR
                LT: 2+.  2+ 2+  -     -.    F-PLANTAR
 
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.

Sugar Trends in Patient 



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 weakness 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 


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 

Done Under the Guidance of- 

Dr. Vara Prasad (Intern)
Dr. Chandana (PG)
Dr. Rakesh Biswas (HOD) 



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