65M with Right 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.
8 November 2023
A 65 year old male came to the opd with chief complaints of weakness and tingling sensation in right upper limb and lower limb since 4 yrs and increased frequency of micturition since 1 month
History of presenting illness -
Patient was apparently asymptomatic 4 yrs back then he developed weakness and tingling sensation in right upper limb and lower limb which is sudden in onset and non-progressive in nature. Pt was unable to get up from bed and was taken to Suryapet hospital and was diagnosed to have left basal ganglion bleed.
CT REPORT DATED Jan 2019
C/o numbness and tingling sensation in rt upper limb and lower limb involving proximal muscles.
C/o increased frequency of micturition since 1 month.
No h/o deviation of mouth, slurring of speech, involuntary movements, squinting of eyes, facial muscle weakness, involuntary bowel and bladder movements.
No h/o fever, cough, nausea, vomiting, diarrheas, sob, palpitations
Past history -
Patient is k/c/o hypertension since 4 yrs on tab ENALAPRIL 2.5mg
N/k/c/o DM, TB, asthma, epilepsy, CAD, thyroid disorders
H/o tibia fracture 6 months ago for which underwent surgery
Personal history -
He is a farmer by occupation
Appetite - normal
Diet - mixed
Micturition- increased
Bowel - regular
No known allergies
No addictions
Family history -
No significant family history
General physical examination -
Patient is conscious, coherent and cooperative and well oriented to time, place and person
No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema
Vitals on admission :
Temp - afebrile
BP - 140/90 mm hg
PR - 86bpm
RR- 16cpm
SpO2 - 98% on RA
GRBS - 97mg/dl
Systemic examination -
CVS : S1, S2 heard; no murmurs
RESP SYS : trachea central, B/l air entry +, NVBS heard, no added sounds
P/A : soft, non tender, no organomegaly
CNS :
GCS - E4V5M6
Higher mental functions - intact
Cranial nerves -
1st CN - sense of smell - N
2nd CN - vision - intact
3rd, 4th and 6th CN - extra-ocular movements - N
5th CN - decreased sensations on right side of face
numbness of tongue and decreased sensation of taste
8th CN - hearing and balance - N
9th CN - decreased taste sensation , pharyngeal reflex - N
10th CN - gag reflex - N
11th CN - shrugging of shoulder against resistance +
12th CN - no deviation of tongue
Sensory system - decreased sensation on both rt upper and lower limb extending upto abdomen
Motor system - bulk - N
tone - N
power - decreased in both rt upper and lower limb 4/5
Rt Lt
B + ++
T + ++
S + ++
K + ++
A + +
Plantar - Mute on both sides
Cerebellar signs - finger nose in-coordination - no
knee heel in-coordination - no
Provisional diagnosis -
Old hemorrhagic stroke of left basal ganglia with HTN
Investigations -
Treatment -
Tab ENALAPRIL 2.5 mg PO OD
Tab PREGABA M 75 mg PO OD
Tab SHELCAL 500 mg PO OD
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