57 YEAR OLD MALE WITH LEFT SIDED HEMIPARESIS

 A CASE OF A 57 YEAR OLD MALE WITH LEFT SIDED HEMIPARESIS


This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.



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.



CHIEF COMPLAINTS



1)Weakness and decreased mobility in both left leg and left arm.


2)Slurred Speech


3)Difficulty in Swallowing


4)Deviation of jaw towards the right side



HISTORY OF PRESENT ILLNESS



The patient was apparantly asymptomatic 6 years ago when he had trauma to leg and was diagnosed with Diabetes Mellitus and has been put on OHA, a split skin graft was performed.



2 years ago, the patient had episodes of amnesia which improved over time. 



2 days back when he suddenly developed weakness on the left side. This was first noticed by the attenders when the patient was unable to hold the mug to wash his face. He simultaneously also developed slurring of speech, drooling on the left side and difficulty in swallowing.




PAST HISTORY



Patient is a known case of Diabetes Mellitus since 10 years.


Not a known case of HTN, Asthma, Epilepsy, TB, Leprosy.



PERSONAL HISTORY



Diet -  Mixed


Appetite -  Normal


Sleep - Adequate


Bowel and Bladder - Normal


Addictions - Consumes alcohol on a regular basis.



GENERAL EXAMINATION


The patient is conscious, coherent and well oriented to time, place and person.



Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy and Edema = Absent



Vitals



PR - 68 bpm


BP - 110/80 mmhg


RR - 20 cpm


SpO2 - 98% on RA




SYSTEMIC EXAMINATION



CVS - S1 S2 Heard


RS - BAE


P/A - Soft, Non Tender, Bowel Sound Heard


CNS 


  Tone - Decreased on Left Side


POWER                  RIGHT             LEFT

UPPER LIMB         5/5                    4/5

LOWER LIMB        5/5                    4/5


REFLEX                 BICEP                TRICEP              SUPINATOR

RIGHT                    2                        2                       2

LEFT                       3                        3                       3


 Right Knee


Left Knee



Right biceps



Left biceps 



Right triceps 


DECREASED  GRIP STRENGTH   


Gait 


CLINICAL IMAGES






Investigations 









PROVISIONAL DIAGNOSIS


 Left sided Hemiparesis with UMN facial palsy secondary to acute infarct in MCA territory.



MANAGEMENT

  • Inj. OPTINEURON 1 Amp in 100ml NS slowly
  • Inj. PANTOP 40mg IV OD
  • Inj. ZOFER 4mg IV
  • Ryles Feeding
  • Tab. ECOSPRIN 325mg PO
  • Tab. CLOPIDOGREL 150mg PO
  • Tab. ATORVAC 80mg PO
  • Monitor Vitals, GRBS
  • Physiotherapy.



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