Medicine long case -70 year old male with right sided muscle weakness

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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 diagnosis and treatment plan.

Reg no : 1701006054

Case; 

A 70 year old male complaints of weakness in his right upper and lower limbs admitted on 6th June 

Chief complaints 

Patient complaints of ; 

Weakness of right upper and lower limbs 

Slurring of speech 

History of presenting illness:

Patient was apparently asymptomatic 4 days back 

Then he suddenly developed weakness in his right upper limb while eat 

Then weakness in his right lower limb 

Then deviation of his angle of mouth to left side 

Then slurring of speech developed 

Past history ;

The patient was leading a peaceful life with his wife. He would wake up every day at about 6am, freshen up, have breakfast and do his daily chores like grazing the cattle till the afternoon. He would then have lunch and take a nap till evening. He then hung out with the neighbours, had dinner and rested for the day. This was his routine for the past 8 years 

1st episode: Patient had been asymptomatic until 3 years ago when he suddenly acquired weakness in his right upper and lower limbs, with no slurring of speech. After being treated, he was able to recover. 

2nd episode: He suffered a second episode of abrupt onset weakening of the right upper and lower limbs a year ago, which was accompanied by drooping of the mouth and saliva dribbling. He was treated for it again and fully healed. 

not a known case of diabetes, asthma, epilepsy, or TB. diagnosed with hypertension 10 months ago and has been using atenolol 25mg since.

            Personal history;

Diet : stopped non-veg 5 years back 

Appetite: normal 

Sleep: adequate 

Bowel and bladder : normal 

Addictions: occasional alcohol 

No allergies 

             Family history: 

Insignificant 

               General examination 

Patient is conscious cooperative 

Well oriented to time but not place and person 

Moderately built and nourished 

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

Vitals; 

Temp: afebrile 

BP:140/80 mm of hg 

Respiratory rate:16bpm

Pulse rate: 70bpm

Spo2 :98%

         Systemic examination ;

CVS: s1 s2 heard 

        No murmurs 

Respiratory system; normal vesicular breath sounds are heard 

Abdomen: soft non tender no organomegly

CNS;

Higher functions:

Right handed 

Conscious 

Oriented to time not place and person 

Memory: recent- present 

              Immediate: present 

              Remote: absent 

Speech:

            Not spontaneous 

            comprehension- present 

            Naming- absent 

            Repition- absent 

            Disarticulation of speech - present 

No delusions or hallucinations 

Cranial nerve examination:

I- Olfactory nerve-  sense of smell present 

II- Optic nerve- direct and indirect light reflex present

III- Oculomotor nerve, IV- Trochlear and VI- Abducens- no diplopia, nystagmus or ptosis

V- Trigeminal nerve- Masseter, temporalis and pterygoid muscles are normal. Corneal reflex is present.

VII- Facial nerve- face is symmetrical, unable to do forehead wrinkling, left nasolabial fold prominent than right.

VIII- Vestibulocochlear nerve- no hearing loss

IX- Glossopharyngeal nerve. X- Vagus- uvula not visualised

XI- Accessory nerve- sternocleidomastoid contraction present

XII- Hypoglossal nerve- Movements of tongue are normal, no fasciculations, no deviation of tongue

 

Spinomotor system:

                                            Right                         Left  

BULK:              U/L- arm        24.5 cm                26 cm                                  

                            -forearm       18 cm                   18 cm   

                                      

                         L/L- thigh      44 cm                     44 cm

                                - leg        28 cm                     28 cm

                  

TONE:            U/L       decreased                       normal

                        L/L        decreased                       normal

                          

4c) Sensory system examination:

                                          Right                                  Left  

• crude touch                  present                             present
• fine touch                      absent                             present               
• pain                               absent                             present
• vibration                      absent                              present
• temperature                     absent                            present
• stereognosis-                  absent                              present 
• 2 pt discrimination-           absent                        present
• graphaesthesia-                  absent                          present 

                                           Right                                  Left 

POWER:       U/L- hand           0/5                                   5/5

                            - elbow         0/5                                   4/5

                            - shoulder     0/5                                     5/5

                    L/L- hip              0/5                                   4/5

                           - knee           0/5                                   5/5   

                            - ankle          0/5                                   4/5

                                       Right                                        Left        

REFLEXES:    Biceps                +++                                ++

                        Triceps                 +++                                    ++

                    Supinator                 +++                                    ++

                          Knee                 +++                                     ++

                        Ankle                  +++                                     ++

                          Plantar          extension                          neutral

 COORDINATION:  Absent 

GAIT 

INVESTIGATIONS:

CBP

• Hemoglobin- 12.6 gm/dl (N)
• PCV- 35.2 % (N)
• TLC- 8600/ cumm (N)
• RBC- 4.33 million/cumm (N)
• Platelets- 2.58 lakhs/ml (N)

Blood urea- 24 mg/dl (N)

Serum creatinine- 1.3 mg/dl (N)

Serum sodium- 136 mEq/L  (N)

Serum potassium- 3.7 mmol/l (N)

Serum chloride- 104 mEq/L (N)

LFT

Total bilirubin- 0.61 mg/dl  (N)

Direct bilirubin-  0.16 mg/dl (N)

SGPT- 11 (N)

SGOT- 13 (N)

ALP- 105 IU/L (N)

Albumin- 4 g/dl (N)

ECG

MRI

PROVISIONAL DIAGNOSIS:

Acute ischemic stroke causing right sided hemiplegia (left MCA territory)

Recurrent CVA 

TREATMENT:

Tab. Ecosporine 150mg

Tab. Clopidogrel 75 mg

Tab. Atorvas 40mg

Tab. Atenolol 25mg

Physiotherapy