66M with Right sided 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.

DOA: 13/11/2023

CHIEF COMPLAINTS:

Weakness in right upper and right lower limbs since 4 hours

Deviation of angle of mouth and slurring of speech since 4 hours 

Altered sensorium since 4 hours 

HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 4 hours ago and then he developed weakness in right upper limb and right lower limb which is sudden in onset, non progressive, and is associated with altered sensorium, deviation of angle of mouth and slurring of speech. 

There is h/o urinary incontinence 

There is no h/o involuntary movements, fecal incontinence, regurgitation of food, fever, headache, nausea, vomiting, cough, breathlessness, abdominal pain, burning micturition.

PAST HISTORY:

K/c/o DM type 2 and HTN since 2 years, on medication Glimepiride 1mg, Metformin 500mg, Amlodipine 5mg and Telmisartan 40mg

PERSONAL HISTORY:

The patient is a daily wage worker by occupation 

Diet is mixed

Appetite is normal

Sleep is adequate

Bowel and bladder - The attender described occasional urinary incontinence 

Addictions - h/o smoking beedi (2 per day) since 40 years, along with occasional alcohol consumption

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative

Well oriented to time, place and person 

Well-built and nourished 

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

On examination there are multiple scaly annular lesions of varying sizes on the skin of the arms and abdomen - 

?Tinea corporis et cruris

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 - E1V2M2 

Higher mental functions - cannot be assessed 

Cranial nerves -  Cannot be elicited 

Sensory system - Cannot be elicited 

Motor system - 

bulk - N 

tone - N on left side, increased in right UL and LL

power - cannot be elicited 

                                     Rt           Lt 

                     B           ++             + 

                     T            -               -

                     S            -               -

                     K           +               +

                     A            -                -

                 Plantar -    Extensor on both sides 

Cerebellar signs - cannot be elicited                           

INVESTIGATIONS

TREATMENT 

RT feeds 100ml milk 4th hourly and 50ml water 2nd hourly 

Tab Ecosprin 75mg RT/OD

Tab Clopidogrel 75mg RT/OD

Tab Atorvastatin 20mg RT/OD

Tab Metoprolol 25mg RT/BD 

Inj Piptaz 4.5g IV/TID

Inj Metrogyl 500mg IV/TID

GRBS 7 O monitoring 

Strict I/O charting 

PROVISIONAL DIAGNOSIS 

Recurrent CVA 

Acute infarct in left frontal and parietal lobe 

Hypertensive emergency(resolved)

Type 2 DM

AKI