Left sided weakness under evaluation (upper limb and lower limb
Date 12/7/23
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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.
Chief compliants:
Chief compliants of difficulty in walking since 5 to 6months
c/o Left sided Pain and weakness since 4 to 5 months both upper and lower limbs
HOPI:Patient was apparently asymptomatic 5 to 6 months ago then she had difficulty in walking, due to which is unable to do her routine work along with
c/o weakness in left lower and upper limbs,
weakness is insidious onset gradually progressive in nature
Pain and tenderness present in the deltoid area (left side) and pain aggravated on over head abduction and tenderness present.
Patient has radicular pain in the left lower limb from hip to toe, which is aggravating on walking,
Due to pain Pateint while walking she feels as if she’s going to fall down
c/o pain in the left deltoid region since 5 to 6 months with c/o pain during movement
no c/o restriction of movement
History of past illness:
History of trauma slip and fall to the left leg 2 yrs back
Patient was completely alright 1.5 yrs after trauma
No h/o head trauma and LOC
No ent bleed
Not aK/c/o HTN, DM CVA CAD,TB asthma etc
On examination:
Pt is conscious, coherent, cooperative
BP:110/80 mmHg
PR:80 bpm
RR:16 cpm
CVS:s1, s2 heard no murmurs
RS:BLAE+ no added sounds
P/A : soft and non tender
Tone :RT LT
UL.
LL
Power RT LT
UL 5/5. 5/5
LL. 5/5. 5/5
Reflexes RT. LT
Biceps. 3+. 3+
Triceps. 1+. 1+
Supinator. 3+. 3+
Knee. 1+. 1+
Ankle 2+. 2+
Hoffman sign +. +
2d echo
Provisional diagnosis:
Lt sided weakness under evaluation
? cerebellar involvement
Treatment:
1 tab mvt po/od
2 tab pregabalin m 75 mg po/hs/9 pm