A 70 yr old male with weakness in his right upper limb
2 December 2022
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 .
Khushi Tulsyan
Roll no. 75
A 70 yr old male patient resident of xxxx farmer by occupation presented to OPD with chief complaints of weakness in right hand and is unable to make a fist of his right hand since 4 days.
HISTORY OF PRESENTING ILLNESS-
Patient was apparently asymptomatic 1 yr ago then he developed weakness in his left hand and had decreased movements on his little and ring finger and could not fold it. He was taken to hospital and there he was given medicines and sent home which he took for like 2-3 months(medicines not recollected by patient)
Then 4 days back when he got up in the morning he could not fist his right hand and had difficulty in eating with it and also couldn’t catch anything in his right hand.
He then presented to our hospital.
He is having slurring of speech since 2 days and was not associated with any facial deviation.
He is having shortness of breath grade 1 since 4 days - on climbing up and down the stairs.
He can feel touch, pain and temperature on his right hand.
There is no history of fever ,trauma , loss of consciousness, nausea and vomiting, decreased sensation ,recent infections and seizures
PAST HISTORY-
He had blurring of vision in his both eyes for which cataract was diagnosed and he was asked to have surgery of his left eye first followed by right eye. After left eye cataract surgery he was sent back. He cane back after 2-3 months where the doctors advised him against right eye surgery. But patient still went on with it and after the surgery there was no improvement in his vision and the vision deteriorated completely and he could not even perceive light via his right eye now.
5 yr back patient had an sudden onset chest pain which was squeezing type associated with sweats and palpitations and was brought to our hospital where because of unavailability of medication he was further referred to other hospital where PTCA was done and he was well after that.
He is not a known case of Hypertension,Diabetes,Asthma ,Leprosy,Epilepsy,Thyroid disorders.
PERSONAL HISTORY-
Diet - Mixed
Appetite - Normal
Bladder and bowel - Regular
Sleep - Adequate
Allergies - None
Addictions - Smoking since 50 yrs with 15-20 beedis/3 days. Didn’t smoke since last 3 days.
Alcohol occasionally.
He wakes up early in the morning 5:30 to 6:00 AM and then he goes out for a walk in the fields and then comes back home and watches TV and takes rest. He has stopped going to his work since 3 years due to his age and this has been his routine since.
FAMILY HISTORY-
No significant family history.
GENERAL EXAMINATION-
Patient is conscious coherent and co operative well oriented to time place and person.He is moderately built and nourished.
Patient was examined in a well lit room and consent was taken.
Vitals -
PR-78 bpm
BP- 120/80 mmHg
RR-16cpm
SPo2- 99 ra
Temp-Afebrile
Pallor - Absent
Icterus - absent
Clubbing - Present
Cyanosis- Absent
Lymphadenooathy- absent
Edema - Absent
CLINICAL PICTURES-
SYSTEMIC EXAMINATION-
CNS-
Higher Mental Functions-
Right handed individual
Conscious coherent and co operative well oriented to time space and person
Patient is emotionally stable and his behaviour and appearc is appropriate
Slurring of speech is present
Fluency is present . Reptation intact.
Recent immediate and remote memory is intact.
Gait -
Cranial Nerves Examination-
Olfactory -Normal
Optic - Rt - No perception of light. Non reactive pupil.
Lt - Visual activity is 12/6 . Pulpils are reactive
Oculomotor trochlear and abducens - Rt - No light reflex. Extraocular movemts are normal
Lt - Light reflex is present. Extraocular movements are normal.
Trigeminal - Senastions present over forehead , chin and cheek
Cornal and conjuctival reflexs are normal.
Jaw jerk is present.
Facial - Forehead wrinkling present.
Ability to close eyes present.
Slight absence of nasolabial fold on right side.
Slight mouth deviation towards right side.
Vestibulocochlear is normal
Glossopharyngeal and vagus nerve Normal
Gag reflex is present.
Spinal accessory - Shrugg reflex present
Hypoglossal nerve - Normal tone. No tongue deviations.
Motor Examination-
Tone - Normal tone of both ul and ll
Power - Ul Rt - 3/5 ( Proximal>Distal) Lt - 4/5
Ll Rt - 4/5 Lt - 4/5
Reflexes -
Superficial - Corneal conjuctival abdominal and plantar reflexes present on both sides.
Deep -
Rt Lt
Biceps 2+ 2+
Triceps 2+ 2+
Knee 3+ 3+
Ankle 1+ 1+
Sensory System -
Fine touch vibration and joint sense is intact on both sides
Pain and temperature is intact on both sides.
Cerebellar Functions-
Tremors not seen
No signs of meningal irritation.
CVS- S1,S2 heard. No murmurs.
Resp - NVBS. Trachea central.
PA - Soft and non tender.
PROVISIONAL DIAGNOSIS-
Cerebral vascular accident (Recurring?)
INVESTIGATIONS-
Haemogram-
Electrolytes-
ECG-
MRI BRAIN-
Comments
Post a Comment