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
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
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