45 year old male with weakness of upper and lower limbs and joint pains since 1 month

This is an 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 .

Cheif complaints:
A 45 year old male construction worker by occupation came to the op with chief complaints of weakness of left upper and lower limbs since one month 
Tingling sensation in left upper and lower limb since one month
Low back ache radiating to left lower limb since one month.

HOPI:
Patient was apparently asymptomatic 1 month back then he developed weakness of left upper and lower limb suddenly while working in field and from there was taken to a private hospital in khammam where he was diagnosed with acute infarct in posterior limb of internal capsule and thalamus after MRI and was treated there. for that.
He also developed tingling sensation in both left upper and lower limb since then no aggrevating or relieving factors.
Patient also complaints of low back ache radiating toward left lower limb aggrevated by working and relieved by taking rest and medication.
No h/o trauma, no slurring of speech and no deviation of mouth ,loss of consciousness, vomitings, seizures, headache, fever.
Patient is a known case of DM since one month on medication Tab Metformin 500mg OD
Known case of Hypertension since one month on Tab Telmesartan 40mg OD
Known case of CVA on Aspirin Clopidogrel and Atorvastatin OD
Not a known case of TB Epilepsy Thyroid problems CAD.

PERSONAL HISTORY
diet mixed
Appetite normal
Sleep normal
Bowel and bladder regular
Regular alcohol consumer since 10yrs
Chronic smoker since 15yrs
No other addictions.

O/E 

Patient is conscious coherent cooperative
Pallor absent
Icterus absent
Cyanosis absent
Clubbing absent
Lymphadenopathy absent
Pedel edema absent

VITALS:
Afebrile on touch
PR 80bpm
BP 130/90 mm hg
RR 16cpm
SpO2 98% at room air
RS BAE+ NVBS+ no added sounds
CVS S1 S2 heard no murmurs
P/A soft no tenderness
CNS 
Higher mental functions intact 
Power 5/5 in all limbs
Tone Normal in all limbs
Reflexes 
            B. T. S. K. A. P
Right + + +. +. +. Flexor
Left. + + +. +. +. Flexor
No signs of cerebellar incoordination

INVESTIGATIONS:

Treatment given:
T.METFORMIN 500MG PO/OD
T.TELMISARTAN 40MG PO/OD
T.CLOPITAB -A 75/75 PO/OD
T.ATORVASTATIN 40MG PO/OD
T.PANTOP 40MG PO/OD
T.PREGABALIN 75MG PO/OD
T.ULTRACET PO/QID
T.BPLEX FORTE PO/OD

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