65 YR OLD MALE WITH WEAKNESS OF RIGHT UPPER LIMB

202421430 gopal
CASE HISTORY AND CLINICAL FINDINGS
C/O WEAKNESS OF RIGHT UPPER LIMB SINCE 3 MONTHS
HOPI: PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS AGO, THEN HE DEVELOPED
SUUDEN ONSET WEAKNESS IN RIGHT UPPER LIMB,NOT PROGRESSIVE
H/O DIFFICULTY IN MIXING FOOD,TAKING BATH,COMBING
H/O TINGLING AND NUMBNESS OF BOTH RIGHT UPPER LIMB AND LOWER LIMB
NO H/O DEVIATION OF ANGLE OF MOUTH
NO H/O SLURRING OF SPEECH, DIFFICULTY SWALLOWING
H/O COUGH WITH COPIOUS SPUTUM,WHITE COLOR, NON BLOOD TINGED, NON FOUL
SMELLING
PAST HISTORY:
K/C/O CVA SINCE 5 YEARS, NOT ON MEDICTION
HTN SINCE 5 YEARS ON MET XL 50 MG PO OD
DM 5 YEARS ON INJ.MIXTARD 5U-5U
N/K/C/O CAD ASTHMA TB,EPILEPSY
PERSONAL HISTORY: AUTODRIVER BY OCCUPATION,MARRIED,APPETITE
NORMAL,SONSUMES NON VEG, BOWEL AND BLADDER REGULAR
CONSUMED 180 ML/DAY FOR 40 YEARS STOPPED 5 YEARS AGO,COSNUMED BEEDI 1
PACK/DAY, STOPPED 10 YEARS AGO
GENERAL EXAMINATION: PATIENT IS CONSCIOUS,COHERENT COOPERATIV WELL ORIENTD
TO TIME PLACE AND PERSON
NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHADENOPATHY,PEDAL EDEMA
TEMPERATURE-96.8 F
PULSE RATE-82 BPM
RESPIRATORY RATE-28 CPM
BP-150/100 MG HG
SPO2 96%@RA
GRBS-105 MG/DL
SYSTEMIC EXAMINATION:
CVS-S1S2+, NO MURMURS
RS-BAE+,NVBS+,DECREASED BREATH SOUNDS IN LEFT MA,SAA,ISA
PER ABDOMEN- OBESE ABDOMEN, SOFT, NON TENDER, NO ORGANOMEGALY
CNS- CONSCIOUS, PUPILS-NSRL
GCS-15/15 E4V5M6
TONE RIGHT LEFT
UL NORMAL NORMAL
LL NORMAL NORMAL
POWER RIGHT LEFT
UL 4/5 5/5
LL 4/5 5/5
REFLEXES BICEPS TRICEPS SUPINATOR KNEE ANKLE
RIGHT 2+ 2+ + 3+ -
LEFT 2+ 2+ + 2+ -
PLANTAR RESPONSE-
RIGHT-EXTENSOR
LEFT-FLEXOR
FINGER NOSE AND KNEE HEEL INCOORDINATION: NO
INVESTIGATION
COMPLETE URINE EXAMINATION (CUE) 16-05-2024 04:14:PMCOLOUR Pale
yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN ++++SUGAR NilBILE
SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS
NilCRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil
HBsAg-RAPID 16-05-2024 04:14:PM NegativeAnti HCV Antibodies - RAPID 16-05-2024 04:14:PM
Non Reactive
PERIPHERAL SMEAR 16-05-2024 09:39:PM RBC : Normocytic normochromic WBC : With in normal
limits PLATELET : Adequate
HEMOGRAM
HB-11.1 G/DL
TLC-8100
N/L/M/E-77/13/7/3
PCV-31.8
RBC-3.59
PLATELET COUNT-2.67 LAKH/CUMM
2D ECHO DONE ON 16/5/24
IMPRESSION: MILD AR+,TRIVIAL TR+, NO MR
NO RWMA, NO AS/MS NO MR, CALCIFIC AV
GOOD LV SYSTOLIC FUNCTION
GRADE I DIASTOLIC DYSFUNCTION
NO PAH/LV CLOT
IVC-0.8 CMS, COLLAPSING
EF-62%
MRI BRAIN PLAIN DONE ON 16/5/24
IMPRESSION: OLD LACUNAR INFARCTS INLEFT PERIVENTRICULAR REGION AND LEFT
CAUDATE
USG ABDOMEN DONE ON 20/5/24
IMPRESSION: GRADE I RPD CHANGES IN BILATERAL KIDNEYS, GRADE I PROSTATOMEGALY
RIGHT KIDNEY SIZE 8.2X4.1 CMS ,LEFT KIDNEY-8.1X3.7 CMS , CMD PARTIALLY LOST,PCS
NORMAL
USG SWELLING ON UPPER BACK ON 18/5/24
IMPRESSION: E/O 15X7 MM HYPOECHOIC LESION NOTED IN SUBCUTANEOUS PLANE WITH
NO VASCULARITY,NO CALCIFICATIONS,NO DEEPER EXTENSION NOTED IN LEFT UPPER
BACK-LIKELY EPIDERMAL INCLUSION CYST
USG CHEST DONE ON 18/5/24
IMPRESSION- FEW AIR SONOGRAMS IN LEFT LUNG FIELDS- ? CONSOLIDATIONS AND
SUGGESTED FURTHER EVALUATION
HRCT CHEST DONE ON 19/5/24:
IMPRESSSION: ELEVATED DOME OF LEFT HEMI DIAPHRAGM- MOST LIKELY EVENTERATION
ELEVATED DOME OF LEFT HEMI DIAPHRAGM CAUSING MILD COMPRESSIVE COLLAPSE OF
LEFT LUNG LOWER LOBE
COURSE IN THE HOSPITAL: PATIENT WAS ADMITTED I/V/O RIGHT UPPER LIMB SINCE 3
MONTHS AND WAS INVESTIGATED FURTHER AND ON EVALUATION DIAGNOSED WITH K/C/O
CVA SINCE 5 YEARS (OLD LACUNAR INFARCTS), HTN AND DM TYPE II SINCE 5 YEARS.
PATIENT WAS MANAGED CONSERVATIVELY WITH ANTIDIABETIC,ANTIHYPERTENSIVE
PATIENT IS HEMODYNAMICALLY STABLE AT THE TIME OF DISCHARGE
Diagnosis
K/C/O CVA SINCE 5 YEARS (OLD LACUNAR INFARCTS)
HYPERTENSION AND DIABETES MELLITUS TYPE II SINCE 5 YEARS
EPIDERMAL INCLUSION CYST ON LEFT UPPER BACK
TREATMENT GIVEN
TAB.ECOSPIRIN AV (75/10) PO HS
TAB.MET XL 50 MG PO OD 1-X-X
TAB METFORMIN 500 MG PO OD 1-X-X
TAB GABA NT PO BD 1-X-X
TAB DULCOLAX PO STAT 2 TABLETS
SYP.GRILLINCTUS LS 15 ML PO TID
SYP.CREMAFFIN PO TID 15ML-15ML-15ML
ADVICE AT DISCHARGE
TAB.ECOSPIRIN AV (75/10) PO HS
TAB.MET XL 50 MG PO OD 1-X-X
TAB METFORMIN 500 MG PO OD 1-X-X
TAB GABA NT PO HS
TAB.LASIX 40 MG PO BD @ 8AM-X-4PM X 5 DAYS
SYP.GRILLINCTUS LS 15 ML PO TIDX 7 DAYS

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