70 yr old male with acute loss of speech and left upper and lower limb weakness

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE 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 

-->A  70 year old male, resident of Chinakaparthy, Nalgonda district came to OPD with chief complaints of:

- Generalised weakness since 20 days

- Loss of speech and unable to move his left upper and lower limbs since morning on 25th August. 

HISTORY OF PRESENTING ILLNESS:

       Patient was apparently asymptomatic 7 months back,then in Jan,2022 he developed stomach pain and swelling in the legs and got checked up in Nalgonda and diagnosed to have grade 1 fatty liver, GB sludge with calculi and mild right hydroureteronephrosis.

There is a history of decreased bladder control since 20 days.

There is no history of palpitations,chestpain,breathlessness, fever,nausea and vomiting.

PAST HISTORY:

No similar complaints in past.

He is known case of diabetes and Hypertension since one year and was on  regular medication.

 No H/o Tuberculosis, Epilepsy,Asthma.

PERSONAL HISTORY:

Diet - Mixed

Appetite -Normal

Bowel and bladder -Regular. 

Sleep - Adequate

Addictions: consumes Alcohol since 40 years and Smoker consumes 3 to 4 biddi per day.

FAMILY HISTORY:

No signicant Family history

GENERAL EXAMINATION:

Patient is conscious ,coherent ,cooperative

He is moderately built and nourished.

Pallor - Absent

Icterus - Absent

Cyanosis - Absent 

Clubbing -present

lymphadenopathy - absent

Pedal edema - absent

Vitals : on the day of admission

Temperature - Afebrile

Pulse rate - 103 bpm

Respiratory rate - 16 cpm

BP- 180/90 mmHg

SpO2 - 96% on Room air

GRBS - 160mg/dl

SYSTEMIC  EXAMINATION:

CNS Examination:

Face is turned towards Right side.

-Loss of speech

Cranial nerves : 

CN 7- nasolabial fold on left side is less prominent. Deviation of mouth to Right side. Forehead wrinkles are absent on left side.

CN 11-Sternocleidomastod muscle spasm on right side.

Other cranial nerves are normal.

ATTITUDE:

       Left upper limb - flexed and pronated

       Left lower limb - externally rotated

BULK of the muscles - Normal 

 POWER :                Right              Left 

Upper Limb             4/5                 0/5

Lower Limb             5/5                 0/5

TONE :            RIGHT            LEFT

            UL      NORMAL    CLASP KNIFE

            LL      NORMAL     HYPOTONIA

REFLEXES :       Right side.      Left side.

Biceps                   Present          Absent 

Triceps                  Present         Absent.  

Supinator              Present.          Absent. 

Knee                       Present.         Absent

Ankle                       Present.          Absent 

 CVS :S1 ,S2 heard , no murmurs.

RESPIRATORY SYSTEM:BAE Present.

PER ABDOMEN::

Soft and non tender , bowel sounds +

CLINICAL IMAGES:

Investigations:

X RAY