A 53 year old male with tingling and numbness of right upper and lower limbs

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This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted.


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 


GENERAL EXAMINATION:

Patient was consious, coherrent and co-operative. Well oriented to time place and person.moderately  built and nourished 
No pallor 
No icterus 
No clubbing
No cynosis
No generalized lymphadenopathy 
No b/L pedal edema

Vitals
Pulse-74bpm
BP 180/100mmhg
Respiratory rate-18cpm
Spo2-99%
Temp-afebrile 
GRBS:148 mg%


Systemic Examination -
CVS : 
S1 S2 present
No murmurs

RESPIRATORY SYSTEM;
B/l symmetrical chest
Trachea - Central
B/l air entry present
NVBS heard

ABDOMEN:
Shape of abdomen: round
Soft, non tender.
No rigidity or guarding.
BS+

CNS :
E4M5V6 - 15/15
Cranial nerves-intact,normal 
Motor system -
                                   Right.         Left 
           Tone.         UL. N.            N
                               LL   N              N

            
           POWER.   UL  4/5          5/5
                               LL   4/5         5/5 

Reflexes: 
                              Right             Left

Biceps                     2+                 2+
Triceps                   2+                  2+
Supinator               1+                  1+
Knee                        2+                  2+
Ankle                       1+                   1+

Plantars- B/L extensors 

Gait-hemiplegic gait 







Provisional diagnosis:

  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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