70 year old male with left upper and lower limb weakness

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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.

70 year old male farmer by occipation, Resident of Nalgonda came to hospital with chief complaints of inability to lift left upper and lower limb since morning.

HOPI:

Patient was apparently asymptomatic 7 months back then developed bilateral pedal edema for which he went local hospital then he diagnosed with Right mild hydroureteroephrosis,Gall bladder calculi,Fatty Liver.

he developed generalized weakness 20 days back.

On 24 August 2022: After his dinner at 8 PM,he went to bed 9 PM.

On 25 August 2022 Morning when he was about to wake up from the bed,he could not lift his left Upper and Lower limb which was Sudden in onset and there is loss of speech since morning then he was immediately Hospitalised.

There is no H/o fever,head injury,Vomiting Loss of consciousness, palpitation,chest pain.

PAST HISTORY:

No similar complaints in past.

He is known case of diabetes and Hypertension since one year and was on  regular medication.

 No H/o Tuberculosis, Epilepsy,Asthma.

PERSONAL HISTORY:

Diet - Mixed

Appetite -Normal

Bowel and bladder -Regular. 

Sleep - Adequate

Addictions: consumes Alcohol since 40 years and Smoker consumes 3 to 4 biddi per day.

FAMILY HISTORY:

No signicant Family history

GENERAL EXAMINATION:

Patient is conscious ,coherent ,cooperative

He is moderately built and nourished.

Pallor - Absent

Icterus - Absent

Cyanosis - Absent 

Clubbing - present

lymphadenopathy - absent

Pedal edema - absent

Vitals :

Temperature - Afebrile

Pulse rate - 103 bpm

Respiratory rate - 16 cpm

BP- 180/90 mmHg

SpO2 - 96% on Room air

GRBS - 160mg/dl

SYSTEMIC  EXAMINATION:

CNS Examination:

ATTITUDE:

       Left upper limb - flexed and pronated

       Left lower limb - externally rotated

 Face is turned towards Right side.

-Loss of speech

Cranial nerves :  nasolabial fold on left side is less prominent. Deviation of mouth to Right side. Forehead wrinkles are absent on left side.

Other cranial nerves are normal.

                                   Right              Left 

POWER : 

Upper Limb             4/5                  0/5

Lower Limb             5/5                  0/5

TONE :  hypotony of left  lower limb.

          Clasp kinfe rigidity of left upper limb

REFLEXES :       right side.      Left side.

Biceps                   Present          Absent 

Triceps                  Present         Absent.  

Supinator              Present.          Absent. 

Knee                       Present.         Absent

Ankle                       Present.          Absent 

 CVS :S1 ,S2 heard , no murmurs.

RESPIRATORY SYSTEM:BAE Present.

PER ABDOMEN::

Soft and non tender , bowel sounds +

CLINICAL IMAGES:

INVESTIGATIONS:

DIAGNOSIS:

Left sided hemiparesis with Acute infract in Middle cerebral Artety.