60 Years Old Male

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 box
CASE : 
A 60 years old Male Who is a Fisherman by Occupation came with Complaints of Weakness in Left LL since 20 days 
History of Present Illness : 
Pt. Was apparently asymptomatic 2 Months back Then he developed giddiness at his workplace Associated With LOC for 10 Min 
Woked up by his wife & Took Home.
Not associated with Involuntary Movements of Limbs, uprolling of eyes, Tongue Bite, Involuntary Micturition or Defecation.Then He Was Fine for 1 Month .Then he developed Pain in Left Lower Limb which is Dragging Type.Pain Continued for 5 days later he developed Weakness in Left Lower Limb associated with 1 Episode of Involvuntary Micturition.
No H/O Lt.Upper Limb Weakness
No H/O Deviation of Mouth/Slurring of Speech
No H/O Slurring of Speech
Past History : 
Not a Known case of HTN DM TB Epilepsy Asthama CAD & Thyroid Disorder
PERSONAL HISTORY : 
Diet: mixed
Sleep: adequate
Appetite: normal
Bowel & Bladder : Regular
Addictions: 
Pt. Takes alcohol from 14 years of age daily 180-200ml ( for 46 years ) 
Pt.is a Smoker - 20 Beedies for day for 46 years
ON EXAMINATION:
Pt is C/C/C
Vitals at admission:
Temp: Afebrile
BP:140/90mmhg
PR: 72 bpm
RR: 20 cpm
SpO2: 98% @ RA 
SYSTEMIC EXAMINATION :
CVS : S1S2+ No Murmurs
P/A : Soft NT
RS : B/L NVBS + 
CNS : Higher Mental Functions Intact 
CN Examination : Normal
Motar : 
                        Rt.                          Lt.
TONE: UL.     Normal             Normal
             LL.     Normal            Normal

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

REFLEXES: B.     ++                       ++
                    T      ++                       ++
                    S.     ++                       ++
                    K      ++                       +++
                    A.     ++                       ++
                    P.      Flexion            Flexion

CEREBELLAR SIGNS : 
Rombergs Sign : - ve 
Finger to Nose : Coordination Intact
Finger Nose Finger : Coordination Intact
INVESTIGATIONS : 


Provisional Diagnosis : Lt.LL Monoplegia Secondary to Acute Ischaemic Stroke
Treatment : 
T.ECOSPRIN 150MG PO BD
T.CLOPITAB 75MG PO OD
T.ATORVAS 80MG PO OD
T.NEUROBION FORTE PO OD




Popular posts from this blog

48F DM Uncontrolled Sugars ; Lt.Great Toe Amputation

Image
 A 48 years old female resident of Vellemla (Narketpally Mandal) who is a home maker came to Casualty with complaints of  Wound Over Lt Foot Since 1 week  Patient Was apparently asymptomatic 8 years back then developed generalized weakness for which she went to hospital & diagnosed to have DM for which she started using medication TAB.METFORMIN 500MG PO/OD & TAB.GLIMEPERIDE 1MG PO/OD. She was using tablets regularly. In b/w she visited our hospital for 2-3 times then her ?FBS - was <250.  February 2024 She developed a fluid filled bleb over her Lt. Great toe which ruptured Spontaneously & healed after dressing done at local hospital. No H/O of Fever at that time. 10th April 2024  She developed a Wound Near Lt.Great toe associated with Swelling of Lt.LL & fever for which she came to our OPD. Advised for admission but they denied admission Investigations on 10/04/24 :  Hb - 9.4 ; TLC - 23900 ; PLT - 3.65 RBS - 604 ; HbA1C : 8.2% S.Creatinin...
Read more

49F DM with Uncontrolled Sugars

Image
 A 49 years old Female who is a house wife by occupation came with C/O  Fever since 15 days  Patient was apparently asymptomatic 9 years back then she started having bleeding per vagina for which she went to hospital & Diagnosed to have ? Fibroid uterus for which she went to a private hospital in hyderabad for hysterectomy as advised in local hospital. Then she had high sugars for the first time (Around 450mg/dl).So she was admitted in the hospital & hysterectomy was done after controlling the sugars with Insulin.Then she was discharged with Tab.GLIME M1 PO BD & continued the tablet for 3 years along with diabetic diet. Then she came to our OP for Follow then she was prescribed with Tab.GLIME M2 PO BD which she used for 2 years. Then she came to our OP for Follow up then she was escalated to Tab.GLIME M3 PO BD. March 2023 She had ulcer over left great toe for which she was admitted in our hospital & got relieved. November 2023  She had Swelling of Rt....
Read more

70M CKD Sec to RVD

Image
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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT  A 70 year old Male Who was a Farmer by Occupation  came to OPD with C/O  B/L Knee Pains & LBA Since 10 days SOB ; B/L Pedal Edema Since 1 Week  Vomitings Since 3 days  HISTORY OF PRESENTING ILLNESS: Pt Was Apparently Asymptomatic 20 years back and developed Fever for which he went to Hospital and Informed that he has ? Renal Problem for which he Used Some ? Medication for 1 Year & Then He was Fine.5 years Back he was Diagnosed with RVD & Started Using ART. Then He was Fine & 10 Days Back he Started Having B/L Knee Joint Pains & LBA for which He...
Read more