55 year old with weakness of left upper limb and lower limb

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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

55 year old male resident of nalgonda mechanic by occupation came to the opd with chief complaints of weakness of left upper limb and lower limb since 3 days .

     C/o deviation of mouth to right side since 3 days 

     C/o slurring of speech since 3 days 

History of presenting illness:

Patient was apparently asymptomatic 4 days ago (on 26/3 around 8:30 pm), then he developed tingling and burning sensation of  left upper limb and lower limb for which he had gone to the local Dr, where he was given some unknown medication and got relieved of his tingling sensation.

 

On very next day(26/3,Sunday) early in the morning he was unable to get up from his bed because of weakness in his left upper limb and lower limb ,he also noticed deviation of mouth towards right side and slurring of speech 

Past history:

H/o fall from his bike, followed by giddiness 3 years ago . He went to hospital for that and had been told that he has blood clots in the right side of his brain , for which he had been given some unknown medication and was adiviced not to consume alcohol and stop smoking. At this same period he had been diagnosed to have hypertension.

H/o CVA 3 years ago 

After 4 months, he went to the doctor for check up and he had been told that medication was working well ,since then he started smoking again and started consuming alcohol 

H/o kidney infection and hepatomegaly 5 months ago , was treated and got relieved 

K/c/o HTN since 3 years 

No H/o DM ,TB , asthma 

NO H/o any past surgery.

PERSONAL HISTORY:

Diet :mixed 

Appetite:normal

Bowel and bladder : regular 

Sleep : adequate 

Addictions: alcohol daily for the past 30 years (360 ml per day )

Stopped 5 months ago ) 

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

General examination:

Patient is conscious coherent cooperative and well oriented to time place and person 

No signs of pallor icterus cyanosis clubbing lymphadenopathy and pedal edema 

Vitals: 

Temp: a febrile 

Blood pressure: 140/80 mm Hg 

Pulse rate : 52 beats per minute 

Respiratory rate:16cpm

CNS EXAMINATION:

Higher mental function 

Patient is conscious well oriented to time place and person 

No delusions or hallucinations 

Dominant right hand 

CRANIAL NERVE EXAMINATION:

CN 1 : smell sense RIGHT       LEFT 

                                +.               + 

CN 2 : visual acuity normal     Normal 

CN 3 4  6 : extra ocular movement : full 

                   Direct light reflex present 

                    Consensual light reflex present 

                      Ptosis and nystagmus absent 

                       Accommodation reflex present 

CN 5 :        Sensory : over face ,buccal mucosa : normal 

                   Motor: masseter ,temporalis : normal 

                    Reflexes :corneal : normal

                                 Conjunctival : normal 

CN7 :     Motor : nasolabial fold : present 

              Sensory: taste of anterior 2/3 rd of tongue: present 

                Reflexes: corneal conjunctival present 

 CN 8:    Rinnes  +

                Webers  not lateralised 

             Nystagmus : absent     

          

CN 9 and 10 : uulva movemts normal 

MOTOR SYSTEM : 

BULK: Inspection : normal 

             Palpation : normal 

TONE : hypertonic 

Power : UL          5/5              3/5 

             LL            5/6             3/5 

Reflexes :

Superficial: plantar :     Rt                   Lt 

                                    Flexsion          Extension 

DEEP TENDON REFLEXES :

Biceps : +1      - 

Triceps:+1     -

Supinator :+1  -

Knees :+1   - 

Ankles +1  -

Sensory system:

Posterior column: fine touch  normal 

                             Vibration  normal 

Spinothalamic    Pain : normal 

                            Temperature: normal 

Cerebella signs : 

Finger nose test : normal.        -

Heel knee test : normal.          - 

Dysdiadokinasia : negative 

MENINGIAL SIGNS 

neck stiffnesses.  -

Kernigs sign -

Brudzinski sign - 

CVS : s1 s2 heard ,no murmur 

Respiratory system: normal vesicular breath sounds 

PROVISIONAL DIAGNOSIS :

left upper limb and lower limb Hemiparesis .

Investigations:

Carotid doppler

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