75 Y OLD MALE WITH LEFT 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.

75 M k/c/o  HTN and DM  (since 8 years)  came with the complaint of LT sided weakness and deviation of mouth to Rt side. 

Patient was apparently asymptomatic uptill 5 pm yesterday (17/7/21) 

 • At 5 pm - Could not hold the tea cup with his hands and spilled it all over him. Following which his wife applied lotion over his abdomen and they had dinner and watched TV. 

 • At 2 am - He called his wife because he couldnot move his Lt UL and he couldnt talk properly and there was deviation mouth to the Rt. He could not contain his urine - his wife recollects. (he arrived to the hospital with foley's)

 • At 5 am - Went to a local hospital which diagnosed him with LT UL Monoplegia with RT sided  UMN palsy  

CT scan was done 

 • At 9 am - Pt arrived at our hospital. His complaints were the above but we also noticed that he had LT LL Weakness. Could swallow water when given in bottle caps 

 • At 8 pm - Above complaints + decresed ability to swallow - RT was inserted 

No h/o fall or trauma, fever, epilepsy

H/o stopping his medication given for HTN 15 days ago (reason not clear) 

No h/o similar complaints in past. 

Occasionally consumed toddy, does not smoke / consume tobacco or beedi. 

Diet - Mixed 

Appetite - Normal

Sleep - Normal , 

Bowel and bladder - has not passed stools since yesterday

General Examination : 

Pt was conscious, coherent and cooperative. He was oriented to time, place and person. Moderately built and nourished. 

No pallor, Icterus, Cyanosis, Lymphadenopathy. 

Vitals : 

Afebrile

BP 160/100 

PR  80

RR 16 

SpO2 96% 

GRBS  126 

Respiratory System : BAE + , NVBS Heard, Trachea Central 

CVS : S1 S2 Heard, No murmurs

Per Abdomen : Soft and non-tender, Bowel sounds heard. 

CNS : 

Cranial nerves -  Normal except 

Deviation of mouth to RT side and in-abolity to shrug the left shoulder ; 

Recently decreased ability to swallow 

Sensory System - Normal 

Motor System - 

 • Power - Decreased in LT UL and LL 

 • Tone - Decreased in LT UL and LL 

 • Reflexes

                       RT.             LT. 

B                     2+            2+

T                     2+            2+

S                     2+            2 +

K                     3+            3+

A                    1 +            1+ 

Plantar        Flexor.     Extensor 

Provisional Diagnosis : 

CVA ;  LT Hemiparesis 2⁰ to ? Acute infarct in Rt Internal Capsule Rt MCA territory.

Investigations:-

Plan of management:

Admitted in AMC and following investigations were sent - 

CBP, RFT, FLP, RBS, HbA1c, CXR PA view

Treatment: 

1. T. ECOSPIRIN 150 MG OD / RT 

2. T. CLOPITAB 75 MG OD/ RT

3. Inj. Optineuron 1 amp in 100 ml NS OD / i.v.

4. T. PAN 40 MG OD/ RT 

5. T. ATORVAS 40 MG  OD/ RT 

6. RT FEEDS - 100 ML WATER HOURLY AND 200 ML MILK 4TH HOURLY W/O SUGAR 

7.   Inj. HAI s/c TID after GRBS

8. BP/PR/SpO2/ Temp Monotoring