50 year old male with weakness in left upper and lower limb

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centred online learning portfolio and your valuable inputs on the comment box is welcome."I've 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 a diagnosis and treatment plan .

 A 50yrs old  who is a resident of cheruvugattu came with c/o weakness in  left UL and LL since today morning(05/05/23)At 8:00AM

HOPI-

patient was apparently asymptomatic till today morning and attenders noticed that he couldn't get up from bed and complained of weakness in left UL and LL which is of sudden onset and gardually progressive.

-No h/o loss of consciousness, involuntary movements, drooling of saliva, involuntary micturation and defeacation.

 Daily routine- patient wakes up at 6:00Am in the morning and freshens up and to heis sister in law for breakfast and tea and returns home ,watches Tv and have lunch at 12:30PM and sleep in the afternoon and have tea at5:00 Pm and have dinner at 8:00pm.

Past history-

K/C/O Acute CVA (Rt.hemiparesis) 2yrs back.

 -1yr back  came to OPD with c/o urinary incontinence ,drooling of saliva.

 Took medication and left.

 K/C/O  HTN and DM since 2yrs and  on regular medication.

T.metformin 500mg + glimperide 1mg Po/od (mrng)

T.Amlong 2.5mg po/od

PERSONAL HISTORY:

Diet- mixed

Appetite - normal

Sleep -normal

Bowel and bladder -regular

Addictions-

-He is chronic alcoholic since 30 years, stopped 2 years  after  right hemiplegia.

-he chews tobacco since 10 years .

FAMILY HISTORY:

No similar complaints in the family.

TREATMENT HISTORY:

He is on antihypertensives and metformin

GENERAL EXAMINATION:- 

GCS -E4V4M5

-B/L pupils-NSRL

Pallor - absent

Icterus - absent

Cyanosis - absent

Clubbing - absent

Lymphadenopathy - absent

Oedema - absent 

Vitals :- 

Temp - 97.2F

BP - 110/70 mm Hg

Pulse rate - 72 bpm

Respiratory rate - 14 cycles per minute 

SYSTEMIC EXAMINATION:

 CNS EXAMINATION :-

Motor system

Power:-

Rt UL - 3/5 Lt UL-0/5 

Rt LL - 3/5  Lt LL-0/5

Tone:-

Rt UL - Hyper

Lt LL-Hypo

Rt LL-Hyper

Lt LL- Hypo

Reflexes: 

                   Right                    Left

Biceps:      ++                    +++

Triceps:       ++                  +++

Supinator:  +++                    ++

Knee:         +++                    ++

Ankle:            +                   +

Plantar:      flexor.         Extensor

Involuntary movements - absent

Fasciculations - absent

Sensory system - 

-Pain, temperature, crude touch, pressure sensations,Fine touch, vibration, proprioception -normal

Cerebellum - 

Finger nose test , dysdiadochokinesia, Rhomberg test could not elicited.

Autonomic nervous system - normal

• Meningeal sign  

Neck stiffeness -present 

Brudzinski sign -present

Kernigs sign -present.

ABDOMEN EXAMINATION:

Inspection -

Umbilicus - inverted

All quadrants moving equally with respiration

No scars, sinuses and engorged veins , visible

 pulsations.

CVS EXAMINATION 

S1S2 heard,no murmurs.

Respiratory system examination

Bilateral air entry present.

Investigations-

ECG

MRI

10/11/23

11/05/2023

2D echo

Mild TR with PAH;Mild AR;No MR

No RWMA No AS/MS,sclerotic AV

Good LV systolic function

Diastolic dysfunction ,no PE. 

Review 2d echo

Doppler impression-

Raised CIMT in b/l CCA's

b/l CCA and ICA show normal biphasic  wave pattern,calibre and colour uptake

No e/o plaques in b/l CCA'S and ICA'S.

Lumbar puncture done on 06/05/23 at 8:30pm

Fever chart-

Day wise investigation chart-

Haemogram and RFT

15/05/23

16/05/23

17/05/23

18/05/23

19/05/23

20/05/23

23/03/23

24/05/23

25/05/23

26/04/23

27/05/23

28/05/23

29/05/23

OP physiotherapy assessment proforma

Culture and sensitivity

Urine culture

Blood culture

CSF c/s

LFT

CUE

Referral (ophthalmology)

(Pulmonology)

Diagnosis-

Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus 

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

Treatment

1.RT Feeds 

-50ml water every 2nd hrly

-200ml Milk+ 2spoons protein powder every 4th hrly.

2.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.

3.inj.optineuron 1amp in 100ml NS IV/OD.

4.T.Ecospirin-AV 75/10

RT/OD.

5.T.Amlong 5mg RT/OD.

6.Monitor BP,PR,RR,Spo2,Temp

7.GRBS 7 profile

8.physiotheraphy

9.Frequent position change 2nd hrly.

Follow up -06/05/23

GCS-E4V3M5

Vitals :- 

Temp - 97.2F

BP - 130/80 mm Hg

Pulse rate - 90bpm

Respiratory rate - 20 cycles per minute

Motor system

Power:-

Rt UL - 3/5 Lt UL-0/5

Rt LL - 3/5  Lt LL-0/5

Tone:-

Rt UL - Hyper

Lt LL-Hypo

Rt LL-Hyper

Lt LL- Hypo

Reflexes: 

                   Right                    Left

Biceps:      ++                    +++

Triceps:       ++                  +++

Supinator:  +++                    ++

Knee:         +++                    ++

Ankle:            +                   +

Plantar:      flexor.         Extensor

07/05/23-

GCS-E3V3M5

Vitals :- 

BP - 150/90 mm Hg

Pulse rate - 92bpm

Respiratory rate - 18 cycles per minute

Motor system

Power:-

Rt UL - 3/5 Lt UL-0/5

Rt LL - 3/5  Lt LL-2/5

Tone:-

Rt UL - Hyper

Lt LL-Hyper

Rt LL-Hyper

Lt LL- Hyper

Reflexes: 

                   Right                    Left

Biceps:      ++                    ++

Triceps:       ++                  ++

Supinator:  +                    +

Knee:         ++                    ++

Ankle:            +                   +

Plantar:      flexor.         Extensor

08/05/23-

GCS-E3V3M5

Vitals :- 

BP - 140/90 mm Hg

Pulse rate - 98bpm

Respiratory rate - 26 cycles per minute

Motor system

Power:-

Rt UL - 3/5 Lt UL-2/5

Rt LL - 3/5  Lt LL-2/5

Tone:-

Rt UL - Hyper

Lt LL-Hyper

Rt LL-Hyper

Lt LL- Hyper

Reflexes: 

                   Right                    Left

Biceps:      ++                    ++

Triceps:       ++                  ++

Supinator:  +                    +

Knee:         ++                    ++

Ankle:            +                   +

Plantar:      flexor.         Extensor

10/11/23

S  

C/o- weakness in left UL and LL.

Stools not passed

No fever spikes 

 

O: 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 120/80mmhg

PR -108bpm

RR-31cpm

Spo2 96% at 4lit of o2

GRBS - 201mg/dl

Temperature -98.2F

I/O :- 2200ml/980 ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE,NVBS, 

P/A: soft, non tender,bowel sounds can be heard 

CNS:

B/l pupils-NSRL

 meningeal signs-neck stiffness,bruzinski sign,kernig sign -present

Gcs: E3,V3,M5

 Reflexes:

       R       L

B  ++      ++

T   ++       ++

S    +      +

K ++     ++

A   +    +

P  Flexor   Extensor

Tone:

         Rt      Lt

UL.  Hyper hyper

        Hyper hyper

Power:

         Rt.         Lt

UL.    3/5.      2/5

 L  L    0/5.     0/5

A: 

Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus 

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

-stool not passed

P: 

1.RT Feeds 

-100ml water every 2nd hrly

-200ml Milk+ 2spoons protein powder every 4th hrly.

2.Inj.Piptaz 4.5gm IV TID

3.Inj.Clindamycin 600 mg IV TID

4.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.

5.inj.optineuron 1amp in 100ml NS IV/OD.

6.T.Ecospirin-AV 75/10

RT/OD.

7.T.Amlong 5mg RT/OD.

8.Monitor BP,PR,RR,Spo2,Temp

9.GRBS 7 profile

10.IVF - 2NS @75ml/hr

10.physiotheraphy

11.nebulisation - ipravent 2nd hrly,mucomist 2nd hrly,budecort-4th hrly.

12.Frequent position change 2nd .hrly

13.syp.LACTULOSE 15ml/RT/HS.

11/05/23

S  

C/o- weakness in left UL and LL.

Stools not passed

No fever spikes 

 

O: 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 140/80mmhg

PR -110bpm

RR-30cpm

Spo2 98% at 6lit of o2

GRBS - 180mg/dl

Temperature -98.2F

I/O :- 3000ml/1200 ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE,NVBS, 

P/A: soft, non tender,bowel sounds can be heard 

CNS:

B/l pupils-NSRL

 meningeal signs-neck stiffness,bruzinski sign,kernig sign -present

Gcs: E4,V2,M3

 Reflexes:

       R       L

B  +        +

T   +       +

S    +      +

K.  +       +

A   +    +

P  Flexor   Extensor

Tone:

         Rt      Lt

UL.  Hyper hyper

        Hyper hyper

Power:

         Rt.         Lt

UL.    3/5.      0/5

 L  L    0/5.     0/5

A: 

Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus  with Right middle and lower zone consolidation with acute liver injury with UTI..

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

-stool not passed

P: 

1.RT Feeds 

-100ml water every 2nd hrly

-200ml Milk+ 2spoons protein powder every 4th hrly.

2.Inj.Piptaz 4.5gm IV TID

3.Inj.Clindamycin 600 mg IV TID

4.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.

5.inj.optineuron 1amp in 100ml NS IV/OD.

6.T.Ecospirin-AV 75/10

RT/OD.

7.T.Amlong 5mg RT/OD.

8.T.UDILIV 300mg RT/BD.

9.Monitor BP,PR,RR,Spo2,Temp

10.GRBS 7 profile

11.IVF - 2NS @75ml/hr

12.physiotheraphy

13.nebulisation - ipravent 2nd hrly,mucomist 2nd hrly,budecort-4th hrly.

14.Frequent position change 2nd .hrly

15.syp.LACTULOSE 15ml/RT/HS.

12.5.2023

S  

C/o- weakness in left UL and LL.

Stools not passed

 fever spike at 5:00AM

 

O: 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 110/80mmhg

PR -106bpm

RR-28cpm

Spo2 97% at 8lit of o2

GRBS - 157mg/dl

Temperature -98.2F

I/O :- 3000ml/1200 ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE present,grunting +

P/A: soft, non tender,bowel sounds can be heard 

CNS:

B/l pupils-NSRL

 meningeal signs-neck stiffness,bruzinski sign,kernig sign -present

Gcs: E4,V2,M3

 Reflexes:

       R       L

B  +        +

T   +       +

S    +      +

K.  +       +

A   +    +

P  Flexor   mute

Tone:

         Rt      Lt

UL.  Hyper hyper

        Hyper hyper

Power:

         Rt.         Lt

UL.    3/5.      0/5

 L L    2/5.     0/5

A: 

Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus  with Right middle and lower zone consolidation(resolving) with acute liver injury with UTI..

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

-stool not passed

P: 

1.RT Feeds 

-100ml water every 2nd hrly

-200ml Milk+ 2spoons protein powder every 4th hrly.

2.Inj.Piptaz 2.25gm IV TID

3.Inj.Clindamycin 600 mg IV TID

4.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.

5.inj.optineuron 1amp in 100ml NS IV/OD.

6.T.Ecospirin-AV 75/75/10

RT/OD.

7.T.Amlong 5mg RT/OD.

8.T.UDILIV 300mg RT/BD.

9.Monitor BP,PR,RR,Spo2,Temp

10.GRBS 7 profile

11.IVF - 2NS @75ml/hr

12.physiotheraphy

13.nebulisation - ipravent 2nd hrly,mucomist 2nd hrly,budecort-4th hrly.

14.Frequent position change 2nd .hrly

15.syp.LACTULOSE 15ml/RT/HS.

13.5.2023

S  

C/o- weakness in left UL and LL.

Stools  passed

 No fever spike

O: 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 140/90mmhg

PR -127bpm

RR-35cpm

Spo2 94% at 2lit of o2

GRBS - 210mg/dl

Temperature -98.2F

I/O :- 3200ml/1100 ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE present,grunting +

P/A: soft, non tender,bowel sounds can be heard 

CNS:

B/l pupils-NSRL

 meningeal signs-neck stiffness,bruzinski sign,kernig sign -present

Gcs: E4,V2,M3

 Reflexes:

       R       L

B  +        +

T   +       +

S    +      +

K.  +       +

A   +    +

P  Flexor   mute

Tone:

         Rt      Lt

UL.  Hyper hyper

        Hyper hyper

Power:

         Rt.         Lt

UL.    3/5.      0/5

 L L    2/5.     0/5

A: 

Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus  with Right middle and lower zone consolidation(resolved ) with acute liver injury(resolving) with  UTI.

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

-stool  passed

P: 

1.RT Feeds 

-100ml water every 2nd hrly

-200ml Milk+ 2spoons protein powder every 4th hrly.

2.Inj.Piptaz 2.25gm IV TID

3.Inj.Clindamycin 600 mg IV TID

4.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.

5.inj.optineuron 1amp in 100ml NS IV/OD.

6.T.Ecospirin-AV 75/75/10

RT/OD.

7.T.Amlong 5mg RT/OD.

8.T.UDILIV 300mg RT/BD.

9.Monitor BP,PR,RR,Spo2,Temp

10.GRBS 7 profile

11.IVF - 2NS @75ml/hr

12.physiotheraphy

13.nebulisation - ipravent 2nd hrly,mucomist 2nd hrly,budecort-4th hrly.

14.Frequent position change 2nd .hrly

15.syp.LACTULOSE 15ml/RT/HS.

14.5.2023

S  

C/o- weakness in left UL and LL.

Stools  passed

 No fever spike

 

O: 

No pallor ,icterus , clubbing,cyanosis,lymphadenopathy ,pedal edema

Vitals : 

BP- 150/90mmhg

PR -100bpm

RR-25cpm

Spo2 100% at 1lit of o2

GRBS - 210mg/dl

Temperature -98.6F

I/O :- 3000ml/1200 ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE present,grunting +

P/A: soft, non tender,bowel sounds can be heard 

CNS:

B/l pupils-NSRL

 meningeal signs-neck stiffness,bruzinski sign,kernig sign -present

Gcs: E4,V2,M3

 Reflexes:

       R       L

B  +        +

T   +       +

S    +      +

K.  +       +

A   +    +

P  Flexor   mute

Tone:

         Rt      Lt

UL.  Hyper hyper

        Hyper hyper

Power:

         Rt.         Lt

UL.    3/5.      0/5

 L L    4/5.     0/5

A: 

Left hemiplegia sec  to Acute infarct in right superior parietal lobule;Superior frontal gyrus  with Right middle and lower zone consolidation(resolved ) with acute liver injury(resolving) with  UTI.

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

-stool  passed

P: 

1.RT Feeds 

-100ml water every 2nd hrly

-200ml Milk+ 2spoons protein powder every 4th hrly.

2.Inj.Piptaz 2.25gm IV BD

3.TABClindamycin 600 mg RT/BD

4.inj.Human actrapid insulin S/C acc to sliding scale if grbs>200mg/dl.

5.inj.optineuron 1amp in 100ml NS IV/OD.

6.T.Ecospirin-AV 75/75/10

RT/OD.

7.T.Amlong 5mg RT/OD.

8.T.UDILIV 300mg RT/BD.

9.Monitor BP,PR,RR,Spo2,Temp

10.GRBS 7 profile

11.IVF - 2NS @75ml/hr

12.physiotheraphy

13.nebulisation - ipravent 4th hrly,mucomist 4th hrly,budecort-6th hrly.

14.Frequent position change 2nd .hrly

15.syp.LACTULOSE 15ml/RT/HS.

16.Neosporin powder for L/A over bedsore 

17.Ointment Thrombophobe

Discharge summary -

COURSE IN THE HOSPITAL -

Patient is admitted i/v/o weakness in left UL and LL since morning and on further evalution MRI was found to have  acute infarct in right superior parietal lobule,superior frontal gyrus,centrum semiovale,peri ventricular white matter-External watershed territory infarct.

Encephalomalacia with gliotic changes in left  frontal lobe extending to periventricular white matter

K/c/o right hemiparesis in 2020.

On admission

GCS-E4V3M5

MRI was found to have  acute infarct in right superior parietal lobule,superior frontal gyrus,centrum semiovale,peri ventricular white matter-External watershed territory infarct.Encephalomalacia with gliotic changes in left  frontal lobe extending to periventricular white matter.

O/E

Temp - 97.2F

BP - 130/80 mm Hg

Pulse rate - 90bpm

Respiratory rate - 20 cycles per minute 

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION:

Inspection -

Umbilicus - inverted

All quadrants moving equally with respiration

No scars, sinuses and engorged veins , visible

 pulsations.

CVS EXAMINATION 

S1S2 heard,no murmurs.

Respiratory system examination

Bilateral air entry present.

CNS Examination 

B/L pupil NSRL

Power:-

Rt UL - 3/5 Lt UL-0/5

Rt LL - 3/5  Lt LL-0/5

Tone:-

Rt UL - Hyper

Lt LL-Hypo

Rt LL-Hyper

Lt LL- Hypo

Superficial reflexes-

Corneal /conjunctival reflex -normal 

Abdominal reflex-normal

Deep reflexs

Jaw reflex- present

Reflexes: 

                   Right                    Left

Biceps:      ++                    ++

Triceps:       +              +

Supinator:  +                  +

Knee:         ++                  ++

Ankle:            +                   +

Plantar:      decreased    increased

Kernig sign-positive

Brudzinski's sign -positive

LP done

On 06/05/23 

CSF analysis showed no cells 

CSF culture and sensitivity-blood C/S no growth after 24hr of aerobic incubation

Urine C/S-E.Coli>10 power 5 CFU/ML of urine isolated

X-Ray chest-

Consolidatory changes noted in the right lateral aspect of mid and lower zone of lung.

On 06/05/23

 ophthalmology referral was done-Reviewed i/v/o diabetic and hypertensive retinopathy changes and also raised ICP features.

Impression -normal anterior segment,No view  because of thick posterior subscapular cataract

On 07/05/23

TLC count started increasing and was initially started on inj.monocef,pitas,clindamycin

On 09/05/23

Pulmonology referral was done-

Reviewed I/v/o- consolidatory changesnoted in the right lateral aspect of mid and lower zone of lung.

Advised tab.Mucinac 600mg TID RT

Tab.Azithromycin 500mg OD RT

On 09/05/23 there was sudden fall in spo2 levels and there was an impending decision for intubation but later spo2levels maintained.

Right middle and lower zone consolidation (resolving) with acute liver injury (resolving)

Presently on the day of discharge 

GCS-E3V2M3

vitals

BP - 140/90 mm Hg

Pulse rate - 127bpm

Respiratory rate-35CPM

SPO2-97% at room air

LE

SYSTEMIC EXAMINATION:

ABDOMEN EXAMINATION:

Inspection -

Umbilicus - inverted

All quadrants moving equally with respiration

No scars, sinuses and engorged veins , visible

 pulsations.

CVS EXAMINATION 

S1S2 heard,no murmurs.

Respiratory system examination

Bilateral air entry present.

CNS EXAMINATION 

B/L pupil NSRL

Power:-

Rt UL - 3/5 Lt UL-0/5

Rt LL - 3/5  Lt LL-0/5

Tone:-

Rt UL - Hyper

Lt LL-Hypo

Rt LL-Hyper

Lt LL- Hypo

Superficial reflexes-

Corneal /conjunctival reflex -normal 

Abdominal reflex-normal

Deep reflexs

Jaw reflex- present

Reflexes: 

                   Right                    Left

Biceps:      ++                    ++

Triceps:       +              +

Supinator:  +                  +

Knee:         ++                  ++

Ankle:            +                   +

Plantar:      decreased    increased

29.5.2023

Vitals : 

BP- 130/90mm Hg

PR -118bpm

RR- 48cpm

Spo2- 99% on RA

GRBS - 152mg/dl

Temperature -98.4F

I/O :- 2800/1850ml

Cvs: s1,s2 heard ,no Murmurs,jvp not raised 

Rs: BAE present,grunting +

P/A: soft, non tender,bowel sounds can be heard 

CNS:

B/l pupils-NSRL

 meningeal signs-neck stiffness,bruzinski sign,kernig sign -present

Gcs: E4,V2,M3

 Reflexes:

       R       L

B  +        +

T   +       +

S    +      +

K.  +.       +

A   +       +

P   Flexion  extension 

Tone:

         Rt      Lt

UL.  Hyper hyper

        Hyper hyper

Power:

         Rt.         Lt

UL.    3/5.      0/5

 L L    3/5.     0/5

A: 

Left hemiplegia secondary to Acute infarct in right superior parietal lobule;Superior frontal gyrus  with Right middle and lower zone consolidation(resolved ) with acute liver injury(resolved) with  UTI.

K/c/o Right hemiparesis in 2020.

K/c/o HTN and Type 2 DM since 2yrs.

Grade 2 bedsore on Right buttock and left buttock with natal cleft

P: 

1.i.v. Fluids NS and RL at 75ml/hour

2.RT Feeds 

-100ml water every 2nd hourly

-200ml Milk+ 2 spoons protein powder every 4th hrly.

3.Monocef 1gm IV/BD

4.Inj. Metoclopromide 25mg IV/OD

5.Inj.  Clexane 40mg/SC/OD

6.Inj.Human actrapid insulin S/C acc to  grbs>200mg/dl

7.Tab. Ecosprin gold 75/75/10 RT/HS

8.Tab.Amlong 10mg RT/OD

9.Nebulisation with

-Ipravent 6th hourly

-budecort 8th hourly

-mucomist 6th hourly

10.Tab. Nicardia 10mg SOS

11.Ointment megaheal for L/A over bedsore

12. Suction every hourly

13.chest physiotherapy before every feed

14.physiotheraphy-passive movements, streching exercises

15.Frequent change in position