45yr old male, Tractor driver ,came to the OPD with cheif complaints of LEFT LOWER LIMB WEAKNESS

AMC BED 2

Case seen by : 

Dr.Sai Surya(intern )

Dr.Neha (intern )

Dr.Trishaala(intern )

Dr.Varaprasad(intern )

Dr. Akshitha(intern )

Dr.Harika.K (intern )

Dr. Shashikala PG Y 3

Dr. Divya PG Y3

Dr. Rashmitha PG Y3

Dr.Hareen Sr Resident 

Dr.Arjun reddy ass prof 

Dr. Rakesh Biswas hod

45yr old male, Tractor driver ,came to the OPD with cheif 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

               Guidiness

               Normal bowel and bladder movements.

 No any sensory symptoms, tingling, numbness.

          Yesterday night at 12:00AM , he had his dinner , walked into his room and slept ,all by himself. Later after that he wanted to go to washroom, he was NOT ABLE TO LIFT HIS LEFT LOWER LIMB ,if he tries to stand, he was falling off.

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.

O/E

pt is C/C/C

NO pallor icterus, cyanosis,clubbing, lymphadenopathy, edema.

Afebrile temperature

PR:70 bpm

BP:100/60mmhg

RR:18cpm

SPO2:99%

GRBS:350MG/DL , UNCONTROLLABLE SUGARS.

CVS: S1S2+

PER ABDOMEN: SOFT

RS: BAE+

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:

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.

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 weekness 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

Sugar trends 

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 

3/11/21 8pm 120mg/dl 

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