A 55 year old male with left hemiparesis

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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.

Chief complaints- 

A 55 year old male resident of nakrekal came with the complaints of 

*Tingling and burning in his left hand and leg since 17 days

*Chest pain since one week 

History of presenting illness-

Patient was apparently asymptomatic 6 years ago then he had sudden loss of consciousness with weakness hand and leg on his left side with deviation of angle of mouth to the right side while he was routinely delving inside a well.

Was associated with sweating and slurring of speech.

He was then taken to hospital in karimnagar where he was told he had left hemiparesis and was given antiplatelet medication which he is still using

He complains of generalised weakness since one year.

Tingling and numbness since 17 days which was insidious in onset and persistent.

Pain in chest since 7 days on the right side due to fall from bed while he was sleeping which was sudden in onset increasing on inspiration, localised to right upper part of chest nearly 3 cm above nipple for which he is on medication.

Past history- 

History of trauma to head 20 years ago was beaten up by thieves

For which suture were done and medications were taken

Not a known case of DM,HTN,Epilepsy,Asthma and coronary artery disease.

H/o Right eye catarct surgery 1 year ago .

Daily Routine

He wakes up at 5am ,does his routine walk with stick and eats breakfast at 8 am. Then he watches tv and have lunch at 1 pm sleeps for about 2hrs and the goes for walk with stick and have dinner at 8:00 PM and sleep at 10:00 PM. He is not involved in any occupation as of now since 6 years

Personal History

Diet: Mixed 

Appetite : decreased since 2 months

Sleep: adequate

Bowel and bladder: constipated since 15 days

Addictions: smoker since 15 years

He smokes around 12-15 cigarettes every day since age of 40.

Alcoholic since 15 years takes alcohol weekly once since his age of 40.

Family history- 

Similar history in his grand father.

No significant drug or allergic history

General examination- 

Patient is concious coherent cooperative well oriented to time place and person

Well built and nourished

No pallor icterus cyanosis clubbing lymphadenopathy pedal edema

Arm adduction internal rotation elbow flexion and wrist plantar flexion indicating classical pyramidal type of weakness.

Vitals-

Temparature:Afebrile

BP:140/90 mmHg

Pulse Rate:80/min regular normal volume

Respiratory Rate:16 cycles/min

Spo2 : 95%RA

Angle of his mouth appears to be slightly deviated to the right side.

Systemic examination-

CENTRAL NERVOUS SYSTEM:

Conscious and coherent 

Higher Mental Functions Intact.

Cranial Nerves:

Olfactory : intact

Optic: 

VA+ 

colour vision normal 

visual field normal

Oculomotor,trochlear,abducens: 

Pupillary reflexes present 

EOM full range of motion present   

Trigeminal : Sensory intact

Motor intact

Facial : 

Absence of nasolabial fold in left side and slight deviation of mouth towards right

Vestibulocochlear : intact

Vagus, spinal accessory, hypoglossal : intact

Motor Examination:

                     Right                            Left

              UL             LL                UL       LL

Bulk: Normal     Normal       Wasting in both 

Tone: Normal     Normal         Hypertonic

Power : RIGHT     LEFT

Elbow:    5/5            3/5

Flexion:  5/5            3/5

Extension: 5/5         3/5

Wrist:          5/5         3/5

Flexion:       5/5         3/5

Extension:    5/5        3/5

Abduction : 5/5 3/5

adduction: 5/5 3/5

KNEE :- 5/5 3/5

Flexion 5/5 3/5

Extension 5/5 3/5 

ANKLE :- 5/5 3/5

Plantarflexion:. 5/5 3/5

Dorsiflexion 5/5 3/5

Toe 5/5 3/5

Movements:5/5

SUPERFICIAL REFLEXES:

CORNEAL present       

CONJUNCTIVAL present

DEEP TENDON REFLEXES:

                             Right       Left

   BICEPS.               + 2       +3                 

   TRICEPS             + 2        +3                         

   KNEE                  + 3        +3   

  ANKLE                 + 2        +3

PLANTAR Flexion Extension      

SENSORY EXAMINATION:  

Crude touch +

Pain +

Temperature +

Fine touch +

Vibration +

Proprioception +

Two point discrimination +

Tactile localisation +

CEREBELLAR EXAMINATION:

Able to perform finger nose test heel knee test

He couldn't perform dysdiadochokinesia on left side

Normal speech

Rhombergs test -ve

No signs of meningeal irritation 

RESPIRATORY SYSTEM:

Bilateral air entry +

Normal vesicular breath sounds heard

CARDIOVASCULAR SYSTEM:

S1 and S2 heart sounds +

no murmurs

ABDOMINAL EXAMINATION:

Soft , non tender

No organomegaly

Investigations- 

Complete blood picture-

Lipid profile-

LFT-

ECG-

Chest x ray-

RBS, PPBS, Sr.creatinine, Urea 

Within normal range

Provisional diagnosis-

Left Hemiparesis associated with UMN Facial palsy ( left side of face)

Acute ischemic stroke in right MCA territory??

TREATMENT-

1. INJ OPTINEURON IV OD

(1 ampule in 100 mL NS)

2. TAB PREGABLIN 75mg po/HS

3. TAB ECOSPIRIN AV (75/20) po/Hs

4. TAB PAN 40mg po OD BBF

5. Physiotherapy of Left UL LL

BP PR RR charting 6th hrly