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:
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
PROVISIONAL DIAGNOSIS
Recurrent CVA
Acute infarct in left frontal and parietal lobe
Hypertensive emergency(resolved)
Type 2 DM
AKI
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