70 year old male with weakness of upper and lower limbs, inability to talk
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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.
11/9/23
A 70 years old male farmer by occupation presented to the casualty with complaints of weakness of right upper and lower limb with inability to talk since yesterday
Date of Admission: 08/09/23
CHIEF COMPLAINTS
Weakness of right upper and lower limb since 4 days (8/9)
Inability to talk since 4 days(8/9)
Patient was apparently asymptomatic till last Friday afternoon (8/9/23). He had his lunch around 12pm after which he called his grandchildren to have a chat and after which marked weakness in right upper and lower limbs and was not able to get up from the bed, also he was unable to speak. His family members thought it to be simple weakness due to old age so they ignored it. They used diapers for urine and stool. Next morning (9/9/23) weakness persists and he was not able to talk so they came to our hospital.
- Weakness was sudden in onset non progressive. No aggravating or relieving factor.
- Slurring of speech was present since 1 year and progressed to inability to talk after this episode.
H/o Drooling of saliva
H/o hiccups
No h/o deviation of mouth
No h/o involuntary movements,
H/o bladder and bowel incontinence
No h/o loss of consciousness
No h/o breathlessness , cough, fever, palpitation, vomiting.
HISTORY OF PAST ILLNESS
Patient had similar complaints 1 year back for which he took medication(?) for 3 months and as symptoms got improved he left the medicine.
K/c/o CVA (left hemiparesis) 1year back
K/c/o HTN since 2 years
N/k/c/o Diabetes, epilepsy, TB, Asthma
DRUG HISTORY
- tablet amlodipine 5mg
- tablet atenolol 50mg po/od
PERSONAL HISTORY
➤Occupation: Farmer
➤Patient is married .
➤Patient takes mixed diet and has a normal appetite.
➤Bowel and bladder movements are normal
➤No known allergies .
➤Addictions - Consumes alcohol regularly
General Examination :
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema.
VITALS :
➤Temperature : 98.2℉
➤PR : 74 beats per minute
➤BP : 160/90 mm Hg
➤RR : 20 cycles per minute
➤SpO2 : 98% in room air
➤Random blood sugar : 269 gm/dl
SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM EXAMINATION
➤Conscious and coherent
➤Speech : lost
➤No signs of meningeal irritation
Motor system
Bulk of the muscle -
No wasting present.
Tone:-
Rt UL - Hyper
Rt LL- Hyper
Lt UL-Hypo
Lt LL- Hyper
Power:-
Rt UL - 0/5
Lt UL-3/5
Rt LL - 0/5
Lt LL-3/5
Reflexes: R. L
Biceps. 2+ 3+
Triceps. 2+ 3+
Supinator 2+ 2+
Knee 2+ 3+
Ankle. 2+ 2+
Plantar. Extensor Extensor
Involuntary movements - absent
Fasciculations - absent
sensory tests cannot be elicited
Cerebellum -
Finger nose test , dysdiadochokinesia, Rhomberg test could not elicited.
Autonomic nervous system - normal
• Meningeal signs -
Neck stiffness -absent
Brudzinski sign -absent
Kernigs sign - absent
CARDIOVASCULAR SYSTEM EXAMINATION
➤s1 and s2 heard
➤Thrills absent.,
➤No cardiac murmurs
RESPIRATORY SYSTEM
➤Normal vesicular breath sounds heard.
➤Bilateral air entry present
➤Trachea is in midline.
ABDOMINAL EXAMINATION
INSPECTION
➤Shape - Scaphoid
➤Equal movements in all the quadrants.
➤No visible pulsation, dilated veins and localized swellings.
PALPATION
➤Liver , spleen not palpable.
➤No tenderness
PROVISIONAL DIAGNOSIS : RIGHT HEMIPARESIS
RECURRENT CVA WITH K/C/O HYPERTENSION SiNCE 2 YEARS
INVESTIGATIONS :
On 9/9/23-
Hb - 13.4
TLC - 11000
Plt count- 3.18
PCV- 38.4
Serum creatinine- 1.3
Serum Na+ 131
Serum K+ 3.2
Cl- 98
Blood urea- 41
RBS- 210
On 10/9/23
Hb- 13.3
TLC-14,300
Plt count- 3.1
PCV- 38.3
Urinary chloride- 189
Spot urinary K+ 25
Spot urinary Na+ 140
FBS - 259
On 11/9/23
Hb- 13.4
TLC - 14,300
PCV- 39.6
Plt count- 3.21
TREATMENT
1) Ryele's tube feeding - 2nd hourly water and 4th hourly milk
2) Ecosprin - AV 75 mg/hr PO OD
3) Atenolol 50mg
4)Physiotherapy
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