57 year old male with lower limb weakness
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan
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.
CONSENT WAS GIVEN BY BOTH PATIENT AND ATTENDERS
Case :
A 57 year old male autodriver by occupation came to the opd with a complaint of
difficulty in walking since 7 days
Giddiness since 7 days
History of presenting illness:
Patient was apparently asymptotic 2 months back and later developed pain in the lower limbs.Since 7 days the patient hasn’t been able to walk having weakness in the lower limbs and swaying towards right side which was incidouus in onset . there is no diurnal variation in weakness of the limbs
He is an auto driver by occupation and he developed pain in lower limbs , for which he has visited a local RMP and given a medication ( unknown)
The next day he developed excessive sweating and associated with vomiting which was non projectile non bilious and watery ( 2- 3 episodes), giddiness , weakness of lower limbs and swaying to right , he visited a local hospital CT was done and medication was given and referred to our hospital on day of admission in evening he perceived the objects as two ( diplopia) which resolved spontaneously after 30 min.
There is a history of fever nearly 1 month back which was diagnosed as typhoid and medication was given
No h/o trauma
He was diagnosed with HTN 1 year back which was incidental finding he took medication for 3 months after that as the HTN was normal he stopped taking medication until now
Past history
there is no history of similar complaints in the past
HTN : since 1 year
Not a case of diabetes , asthma , copd , TB , epilepsy
H/ o typhoid fever 1 month back
Personal history
Marital status : married
Diet : mixed
Appetite : normal
Bowel and bladder: he has constipation (once in 2 days ) bladder movements are regular
Sleep : adequate
Addictions :
A chronic alcohol for 20 years and stopped 2 years back
And a chronic smoker for 22 yrs consumed in form of beedi.
General physical examination
Patient was concious coherent cooperative moderately built and nourished , well oriented to time place and person
Pallor : absent
Icterus : absent
Cyanosis : absent
Clubbing : present
Lymphadenopathy : absent
Edema : absent
Vitals
Temperature : 98.6° F (afebrile)
PR : 86 bpm
BP : 180 / 100 ( 5/09/2022 , 5pm)
RR : 18 cpm
Systemic examination
CNS :
HIGHER MENTAL FUNCTIONS:
Oriented to time place and person
Immediate memory:Intact
Short term memory:Intact
Longterm memory:Intact
No delusions and hallucinations.
CRANIAL NERVES:
Olfactory nerve(I): Smell is intact
Optic nerve(II):size of both pupils equal.
Pupil reactivity to light:present
Direct and indirect light reflex are present in both eyes.
Oculomotor(III),Trochlear(IV)and Abducens(VI):ocular movements present.Brief period of diplopia,No ptosis,Horizontal Nystagmus Present
Trigeminal(V): Sensations over the face present.
Corneal reflex:present
Jaw jerk: Absent.
Muscles of mastication:Normal(No wasting)
Facial nerve(VII): No deviation of mouth
The wrinkles on both sides of forehead are present.
Taste:intact.
Secretions:Normal in eyes.
Vestibulocochlear nerve(VIII):Hearing intact.
No positional vertigo and nystagmus.
Glossipharyngeal (IX) and Vagus(X): uvula is centre and pilatoglossus pillars are normal and gag reflex intact.
Taste sensations from posterior tongue is normal.
Spinal accesory(XI):Trapezius and Sternocleidomastoid normal.
Hypoglossal(XII): Tongue (opening )central in postion.
No weakness and wasting of tongue.
Tongue moments normal.
MOTOR SYSTEM:
No visible muscle wasting is seen on inspection.
TONE OF THE MUSCLE:
Right: upper limb—Normal tone
lower limb—Normal tone
Left:Upper limb—-Normal tone
lower limb—-Norma tone.
POWER OF MUSCLE:
Right upper limb: 5/5
(Tested for supraspinatus,Deltoid,infraspinatus,Rhomboid,pectoralis major,latissimus dorsi,biceps, brachioradialus, triceps,Extensor carpi radialis, Extensor carpi ulnaris,Extensor digitorum,Flexor carpi radialis and Flexor carpi ulnaris,Abductor pollicis longus, Extensor pollicis brevis,Extensor pollicis longus,Lumbricals,Abductor digiti minimi.)
Right lower limb:5/5
(Tested for Quadriceps femoris,Tibialis anterior,Tibialis posterior,Gastrocnemius,peronei,Extensor digitorum longus,flexor digitorum longus,extensor digitorum brevis,extensor hallucis longus)
Left upper limb:5/5
Left lower limb:5/5
POSTURE AND GAIT:
Broad based gait
No involuntary movements or tremors are seen.
SENSORY SYSTEM:
Fine touch, crude touch and pain intact in all the four limbs.
Temperature: Differentiation between cold and hot objects present.
Joint position:5/10 (incorrect)in Right lowerlimb and 5/10 (incorrect)in left lower limb.
No abnormal sensations are present
REFLEXES:
Tendon reflexes:
Jaw jerk: Not seen
Right:
Biceps jerk:+++
Triceps jerk:+++
Supinator jerk:+++
Knee jerk:+++
Ankle jerk:+++
Left side:
Biceps jerk:+++
Supinator jerk:+++
Triceps jerk:+++
Knee jerk:+++
Ankle jerk:+++
Superficial reflex:
Abdominal reflex: present
Cerebellar function tests:
Titubation absent
Trunkal ataxia/gait ataxia swaying towards right
No dysarthria,tremors,hypotonia
Coordination tests:
Finger nose test: done by both hands(normal).
No overshooting.
Finger to finger testing:no incordination.
Diadokokinesia: normal with right hand.
Heel knee test: no incordination
Rhombergs test: swaying towards right with eyes open
Steriognosis : intact
Autonomic nervous system:
Increased sweating +
No postural hypotension
Meningeal signs:
No neck pain
No spinal and cranial abnormalities
No carotid bruit
CVS :
Respiratory system:
On inspection :
Shape :
trachea central , bilateral air entry present , symmetrical expansion of chest present , no scars and sinuses
P/abdomen :
On inspection : abdomen was (slightly distended )
No visible scars and sinuses
Umbilicus : central and normal
On palpation : soft and non tender
On percussion
On auscultation : bowel sounds were heard
Investigations:
Comments
Post a Comment