A 53 year old male with tingling and numbness of right upper and lower limbs
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Pt came with complaints of
Tingling and numbness in right upper limb and lower limb since 4 hours
Weakness in right upper limb and lower limbs since 2 hours
Difficulty in walking
HISTORY OF PRESENTING ILLNESS:
Patient was apparently asymptomatic 4 hours ago.
Then he developed tingling and numbness in right upper and lower limbs since 4 hours
Weakness in right UL and LL since two hours and difficulty in walking.
No H/O loss of consciousness, involuntary movements,giddiness, vomitings, pain abdomen, loose stools
No H/O involuntary micturition or defecation .
PAST HISTORY:
K/c/o CVA with right hemiparesis two years ago-on medication since then
K/c/o HTN -on tab.telma 40mg PO/OD
Not k/c/o DM,asthma,thyroid disorders,epilepsy,CAD
PERSONAL HISTORY:
Diet-mixed
Appetite:normal
Bowel and bladder movements -regular
Addictions-alcohol:occasionally
Sleep -adequate
FAMILY HISTORY:
not significant
Recurrent CVA with acute ischemic stroke with acute infract in left internal capsule and corona radiata with HTN (2yrs)
Treatment:
1 tab ecosprin 75 mg+clopidogrel 150 mg+atorvastatin 20 mg po/hs
2.tab.PREGABA-M 75/10 PO/OD
3.tab.cinod 40mg PO/BD
4.physiotherapy of rt upper and lower limb
5.monitor vitals and inform sos
30/6/23:
S:
Tingling and numbness decreased
Stools passed
No fever spikes
O:
Patient is c/c/c
Temp: 98.4 F
PR- 84 bpm
RR-18 cpm
BP-140/90 mm of Hg
Spo2 -98%
CNS:
GCS- E4 V5 M6
Pupils: NSRL
Power -
Rt Lt
UL 4/5 5/5
LL 4/5 5/5
Tone- Rt. Lt
UL N N
LL Hyper Hyper
Reflexes
Rt Lt
B - 2+. 2+
T - 2+. 2+
S. 1+. 1+
K - 2+. 2+
A - 1+ 1+
Plantar extensor extensor
Circumduction gait
RS-B/L air entry present, NVBS
CVS- S1S2present, no murmurs heard
A:
Recurrent CVA with acute ischemic stroke with acute infract in left internal capsule and corona radiata with HTN (2yrs)
P:
1 tab ecosprin 75 mg+clopidogrel 150 mg+atorvastatin 20 mg po/hs
2.tab.PREGABA-M 75/10 PO/OD
3.tab.cinod 40mg PO/BD
4.physiotherapy of rt upper and lower limb
5.monitor vitals and inform sos
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