A 27 YR OLD MALE CAME TO OPD WITH CHEIF COMPLAINTS OF GIDDINESS AND WEAKNESS IN RIGHT UPPER AND LOWER LIMB

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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.

 A 27 yr old male came to opd 

CHEIF COMPLAINTS : 

GIDDINESS SINCE 4 days 

Right upper and lower limb weakness since 4 days 

Slurring of speech since 4 days 

HOPI : 

Patient was apparently asymptomatic 4 days back and then while he was drinving tractor he had 2 episodes of giddiness and then following that he developed Right Upper And Lower Limb weakness, sudden in Onset ,Non Progressive,Unable to lift the hand Above the level of head. Deviation Of angle of mouth to Left side 

Slurring Of speech since 4 days 

No H/O of Trauma  falls.

No H/O Uprolling of Eyeball,involuntary Micturition, defecation 

PAST HISTORY 

Patient has Seizure Disorder since 20 yrs not on medication 

Last episode was 6 years ago 

Not a known case of :

DM,HTN, CAD,CVA,Asthma,TB, Epilepsy

Personal History : 

Diet -mixed 

Apetite -Normal 

Sleep -adequate 

Additiction : Alcohol comsumption -180ml daily 

FAMILY HISTORY : 

No similar complaints in the family  

Treatment history : 

No past surgeries have been done 

No known drug allergy 

GENERAL EXAMINATION : 

Pateineg is conscious coherent and cooperative 

No pallor

 No icterus, No cyanosis, No Clubbing, 

No  Lymphadenopathy,

No pedal edema 

Temp:- 96.8F

PR:-122bpm

RR:-18 cpm

BP:- 200/140 mmHg

SYSTEMIC EXAMINATION:

CVS :- S1s2+ heard 

RS:- NVBS( Non vesicular breath sounds ) 

PA :- Soft , NON TENDER 

CNS EXAMNINATION : 

HIGHER MOTOR FUNCTIONS - Intact 

NO SIGNS IF MENINGIAL IRRITATION 

( Brudzinski sign ,Kernigs sign ) 

CRANIAL NERVES : 

Normal 

SENSORY SYSTEM : 

Decreased Fine touch in Right Side below Knee

MOTOR SYSTEM : 

                   RT            LT 

Tone  UL  hypo       normal

           LL   hypo       normal 

    

Power           RT            LT 

            UL    3/5           5/5

            LL    4/5            5/5

Reflexes     RT     LT

B                  -         1+

T                  -         -

S                  -         -

K                  -         1+

A                  -         -

Investigations

Treatment : 

1.T. ECOSPIRIN PO STAT 

2.TAB.NICARDIA 10 MG PO STAT 

3.TAB. CLOPITAB PO STAT

4.TAB.ATORVAS PO STAT