50yr OLD MALE WITH WEAKNESS IN LEFT UL & LL

This is an online E logbook to discuss our patients' de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with the collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome. 

 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, and investigations, and come up with a diagnosis and treatment plan.

CASE PRESENTATION

The patient came with complaints of

    Weakness of left upper and lower limb since 2days 

     Slurring of speech since 2days

     Deviation of the mouth towards the right side since 2 days

HOPI:

 the patient was apparently asymptomatic 3days back then he developed a tingling and burning sensation in his left upper and lower limbs for which he went to an RMP doctor and was given unknown medication, which relieved the tingling sensation.

on the 26th of March, he couldn't get up from bed due to weakness of his left upper and lower limbs, deviation of mouth to the right side, and slurring of speech.

No h/o giddiness, neck stiffness,  LOC

No c/o weakness, dysphagia 

No h/o seizures

H/o giddiness and fall from the bike 3 years ago and diagnosed as denovo HTN and CT scan were done.

PAST HISTORY:

H/o Grade 1 hepatic encephalopathy (resolved) secondary to alcoholic liver disease with Pre renal AKI(resolved) 4 months back

 H/o CVA 3 years back

K/C/O HTN since 3 yrs

PERSONAL HISTORY: 

Mixed diet

Normal appetite

Normal bowel and bladder habits

Addictions: drinks alcohol daily of 360 ml for 30 years and stopped 5 months back

 Smokes daily of 1 pack for 30 years, stopped 5 months ago

O/E: Patient is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema

VITALS: 

Temp: afebrile

BP: 140/80 mm hg

PR: 52 bpm

Spo2: 97% at RA

RR: 16 cpm

GRBS: 112 mg/dl

CVS: S1S2 Heard

RS: BAE Present

P/A: Soft, non-tender, bowel sounds heard

CNS:                     R          L

Tone- UL            N         Hypotonic

            LL            N        Hypotonic

 Power-UL         4/5    3/5

             LL          4/5    3/5

 Reflexes- Biceps- +1   -

                 Triceps- +1    -

                 Supinator- +1  

                 Knee-      +1    -

                 Ankle-.   +1       -

                 Plantar- flexion extension

INVESTIGATIONS:

Diagnosis: 

Acute ischemic CVA with left UL and LL hemiparesis(Late hyperacute infarct in Right PONS, chronic infarct in Right and Left Frontal and Right occipital)

HTN since 3 years

Treatment:

Inj.. OPTINEURON in 100 ml NS IV/OD

Inj. THIAMINE 200 mg in 100ml NS IV BD

Tab. ECOSPIRIN-GOLD 20mg PO OD

Tab. PANTOP 40 mg PO/OD

Tab. TELMA 40 mg PO/OD

Physiotherapy of left UL&LL