55 Year Male with Left Sided Hemiparesis

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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.

5 January 2022

A 55yr old male came with the chief complaints of

Tingling and Burning sensation in left leg and left hand since 17 days

Chest pain right side since 8days 

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 6yrs ago then he had an episode of sudden loss of consciousness associated with excessive sweating, which was associated with slurring of speech,  deviation of mouth towards right.

He was taken to hospital in karimnagar and diagnosed with left hemiparesis and is under medication (anti platelets) till date.

He now  presents with the complaint of burning sensation in the left upper  and lower limb since 15 days which is persistent throughout day.

He also complains of  right sided chest pain which is sudden onset ,dragging type , non radiating, intermittent in nature not associated with shorthness of breath ,sweating .

Patient complaints of generalized  weakness since 1 year

No history of any other episodes of loss of consciousness, seizures,headache , nausea,vomitings .

PAST HISTORY

Patient had a history of trauma to head 20 years ago

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 cataract surgery 1 year ago .

DAILY ROUTINE

He daily wakes up at 5am ,does his daily 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 go for walk with stick and have dinner at 8:00 PM and sleep at 10:00 PM.

PERSONAL HISTORY:

Diet: Mixed 

Appetite: decreased since 2 months

Bowel - hard stools once in 2 months but now he is passing stools. 

Bladder- Normal

Sleep:Adequate 

Addictions- Smoking since 40yrs ( one bidi packet per day)

Occassionally alcoholic since 30yrs.

FAMILY HISTORY:

H/0 hemiparesis in grand father and father.

DRUG HISTORY:

No significant drug history.

GENERAL EXAMINATION:

Patient is conscious,  coherent and co-operative.well oriented to time,place and person.

Moderately built and moderately nourished.

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

VITALS

TEMPARATURE:Afebrile

BP:130/80 bpm 

PULSE RATE:74/min regular normal volume

RESPIRATORY RATE:16 cycles/min

CENTRAL NERVOUS SYSTEM:

Conscious, coherent  and cooperative, well oriented to time place and person

HIGHER MENTAL FUNCTIONS Intact.

Memory intact 

Speech normal

CRANIAL NERVES

1st : Normal

2nd : Visual acuity is normal

3rd,4th,6th : Pupillary reflexes present

EOM full range of motion present        

5th : Sensory intact

          Motor intact

7th : There is absence of nasolabial fold in left side and slight deviation of mouth towards right

 

8th : No abnormality noted. 

9th, 10th, 11th, 12th : normal

MOTOR EXAMINATION:

Tone - Hypertonia in left upper and lower limb

Power-                     Right Left

              Upper limb 5/5   4/5

              Lower limb 5/5   4/5

Reflexes :

Biceps: Right 2+

              Left: 3+

Triceps: Right 2+

               Left: 2+

Supinator: Right 2+

               Left: 2+

Knee: Right: 2+

           Left: 3+

Ankle: Right: 2+

             Left: 2+

Plantar: Right : Flexion of great toe

               Left: Extension

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch Present 

Pain Present 

Temperature Present 

DORSAL COLUMN SENSATION:

Fine touch Present 

Vibration Present 

Proprioception Present 

CORTICAL SENSATION:

Two point discrimination Present 

Tactile localisation Present 

CEREBELLUM EXAMINATION:

Knee heel test present. 

Able to do finger nose test.

 Dysdiadokinesia absent

Rhomberg test absent

Gait    Gait

SIGNS OF MENINGEAL IRRITATION: 

Kernig's sign, brudzinski sign, neck rigidity

 absent 

RESPIRATORY SYSTEM:

Bilateral air entry present,vesicular breath sounds heard, no adventitious sounds heard. 

CARDIOVASCULAR SYSTEM:

S1 and S2 heart sounds heard,no murmurs

ABDOMINAL EXAMINATION:

Soft and non tender,No organomegaly

PROVISIONAL DIAGNOSIS

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

Old ischemic stroke in right MCA tterritory

INVESTIGATION

Treatment by treating unit

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