A CASE OF A 57 YEAR OLD 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 plan.

CHIEF COMPLAINTS

1)Weakness and decreased mobility in both left leg and left arm since 2 days.

2)Slurred Speech since 2 days.

3)Difficulty in Swallowing since 2 days.

4)Deviation of jaw towards the right side since 2 days.

HISTORY OF PRESENT ILLNESS

The patient was apparantly asymptomatic 10 years ago when he had trauma to leg and was diagnosed with Diabetes Mellitus and has been put on OHA, a split skin graft was performed.

2 years ago, the patient had episodes of amnesia which improved over time. 

2 days back when he suddenly developed weakness on the left side. This was first noticed by the attenders when the patient was unable to hold the mug to wash his face. He simultaneously also developed slurring of speech, drooling on the left side and difficulty in swallowing.

PAST HISTORY

Patient is a known case of Diabetes Mellitus since 10 years.

Not a known case of HTN, Asthma, Epilepsy, TB, Leprosy.

PERSONAL HISTORY

Diet -  Mixed

Appetite -  Normal

Sleep - Adequate

Bowel and Bladder - Normal

Addictions - Consumes alcohol on a regular basis.

GENERAL EXAMINATION

The patient is conscious, coherent and well oriented to time, place and person.

Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy and Edema = Absent

Vitals

PR - 68 bpm

BP - 110/80 mmhg

RR - 20 cpm

SpO2 - 98% on RA

SYSTEMIC EXAMINATION

CVS - S1 S2 Normal

RS - BAE Present, NVBS

P/A - Soft, Non Tender, Bowel Sound Heard

CNS 

The patient is conscious, coherent and well oriented to time, place and person.

•   Tone - Decreased on Left Side

• POWER	RIGHT	LEFT
  UPPER LIMB	5/5	4/5
  LOWER LIMB	5/5	4/5

• REFLEXES	BICEPS	TRICEPS	SUPINATOR	KNEE
  RIGHT	2+	2+	2+	2+
  LEFT	3+	3+	3+	3+

Right Knee

Left Knee

• Right Biceps
  
  

• Left Biceps
  
  
  
  
  

• Left Triceps

• Decreased Grip Strength

Pupillary reflexes, Abdominal Reflex, Cremasteric Reflex and Plantar Reflex - not performed

Gait

CLINICAL IMAGES

INVESTIGATIONS

CT - BRAIN

CBP

CUE

LIPID PROFILE

SERUM CREATNINE

SERUM ELECTROLYTES

FASTING BLOOD SUGAR

THYROID PROFILE

X-RAY CHEST

PROVISIONAL DIAGNOSIS

 Left sided Hemiparesis with UMN facial palsy secondary to acute infarct in MCA territory.

MANAGEMENT

1. Inj. OPTINEURON 1 Amp in 100ml NS slowly
2. Inj. PANTOP 40mg IV OD
3. Inj. ZOFER 4mg IV
4. Ryles Feeding
5. Tab. ECOSPRIN 325mg PO
6. Tab. CLOPIDOGREL 150mg PO
7. Tab. ATORVAC 80mg PO
8. Monitor Vitals, GRBS
9. Physiotherapy