I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
A 45 year old male presented to the AMC with chief complaint of lower limb weakness since one day
The patient is a truck driver, who usually works for transportation of construction material, he gets up early in the morning at around 6:00 am, finishes his morning routine and goes to work by 9:00 am. He drives till afternoon and eats lunch outside with his co workers, resumes work and returns home by 7- 8:00 pm in the evening, finishes his dinner and gets a good 6-7 hour sleep.
HISTORY OF PRESENTING ILLNESS:
The patient was apparently asymptomatic one day ago when he developed weakness in the left lower limb from knee to foot. He noticed at around 12:00 am, when he got up for washroom, that he couldn't stand by himself and fell down when he tried to. He could walk all by himself before sleeping.
It is is acute in onset and not progressive. It wasn't associated with tingling sensation, numbness or loss of sense.
There was no h/o fever, vomiting and diarrhoea
PAST HISTORY:
Patient is not a k/c/o Hypertension, Diabetes mellitus, Epilepsy, TB, Asthma.
Family history: Insignificant
Drug history: Insignificant
PERSONAL HISTORY:
Appetite: Normal
Diet : Mixed
Bowel and bladder movements: Regular
Sleep: Adequate
Takes alcohol occassionally. Doesn't smoke.
No known allergies.
PHYSICAL EXAMINATION;
GENERAL EXAMINATION:
Consent was taken. Patient was examined in well lit room. Patient is conscious, coherent and cooperative.
No signs if pallor, Icterus, Clubbing, Cyanosis, Kolionychia, Lymphadenopathy and edema
VITALS:
He's afebrile
Pulse : 73bpm
Respiratory rate: 18 cpm
Blood pressure: 100/60 mm of Hg
SpO2: 99%
SYSTEMIC EXAMINATION:
CVS S1, S2 heard. No murmurs heard
RESPIRATORY SYSTEM: BAE+
PER ABDOMEN: Soft, non tender
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:
HAEMOGRAM:
HB:13.6
TC:13100
PL:2.89
RBS:382MG/DL
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.
ECG:
CVA L/L MONOPARESIS
?FRONTAL LOBE INFARCT RIGHT SIDE.
?UNCONTROLLED DENOVO DM 2
PLAN OF CARE:
On 2/11/21
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
6. T. Atorvas 40 mg PO/OD
7. T. Aspirin 75 mg PO/OD
8. T. Clopidogrel 75 mg PO/ OD
Patient has been sent to physiotherapy and advised rest and has been discharged after completing follow up.
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