45yr old AMC bed 2


45yr old male, Tractor driver ,came to the OPD with cheif complaints of 
LEFT LOWER LIMB WEAKNESS since yesterday.
 Weakness only from knee to foot.
Acute in onset.
No any progression in weakness.
No H/O vomitings, fever, diarrhoea
NO H/O slurring of speech
               Guidiness
               Normal bowel and bladder movements.
 No any sensory symptoms, tingling, numbness.

          Yesterday night at 12:00AM  , he had his dinner , walked into his room and slept ,all by himself. Later after that he wanted to go to washroom, he was NOT ABLE TO LIFT HIS LEFT LOWER LIMB ,if he tries to stand, he was falling off.

PTCA 3YRS BACK

NOT A K/C/O DM,HTN, ASTHMA, TB, EPILEPSY.

NO significant family history
No significant drug history.

PERSONAL HISTORY:
Takes mixed diet
Appetite is normal
Regular bowel and bladder movements
Adequate sleep
Alcohol, smoking occasionally.

O/E
pt is C/C/C
NO pallor icterus, cyanosis,clubbing, lymphadenopathy, edema.
Afebrile temperature
PR:70 bpm
BP:100/60mmhg
RR:18cpm
SPO2:99%
GRBS:350MG/DL , UNCONTROLLABLE SUGARS.

CVS: S1S2+
PER ABDOMEN: SOFT
RS: BAE+

CNS:
-POWER OF ALL LIMBS 5/5 , EXCEPT 
LEFT LOWER LIMB: 3/5
-REFLEXES OF LEFT LOWER LIMB ABSENT
-PLANTARS - FLEXORS.
TONE OF LEFT LL: HYPOTONIA.
SENSORY:
PROPRIOCEPTION : INTACT
FINE TOUCH +
CRUDE TOUCH +
PRESSURE +
PAIN +
TEMP +
VIBRATION+
POSITION+
Cranial nerves: intact

INVESTIGATIONS:

HEMOGRAM:
HB:13.6
TC:13100
PL:2.89

RBS:382MG/DL

LFT:
TB:1.24
DB:0.64
AST: 18
ALT: 10
ALP: 168
TP: 6.8
ALB: 3.2
A/G: 0.92

SERUM ELECTROLYTES:
Na: 135
K: 4.7
Cl: 96

S . CREATININE: 0.9 MG/DL
BLOOD UREA : 45

CUE:
SUGAR :++++
ALB: NIL
PUS CELLS: 3-6
EPI CELLS: 2-4.

PROVISIONAL DIAGNOSIS:

PTCA 3YRS BACK

CVA L/L MONOPARESIS
?FRONTAL LOBE INFARCT RIGHT SIDE.
?DENOVO DM

PLAN OF CARE:
1.inj.OPTINEURON 1AMP in 100ml NS/IV/OD
2.T. PAN 40MG PO/OD
3.inj.HAI s/c / TID
4.GRBS CHARTING 7 O PROFILE
5.monitor BP,PR,RR.







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