50yr OLD MALE WITH WEAKNESS IN LEFT UL & LL

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. 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


The patient came with complaints of
    Weakness of left upper and lower limb since 2days 
     Slurring of speech since 2days
     Deviation of the mouth towards the right side since 2 days

HOPI:
 the patient was apparently asymptomatic 3days back then he developed a tingling and burning sensation in his left upper and lower limbs for which he went to an RMP doctor and was given unknown medication, which relieved the tingling sensation.
on the 26th of March, he couldn't get up from bed due to weakness of his left upper and lower limbs, deviation of mouth to the right side, and slurring of speech.
No h/o giddiness, neck stiffness,  LOC
No c/o weakness, dysphagia 
No h/o seizures
H/o giddiness and fall from the bike 3 years ago and diagnosed as denovo HTN and CT scan were done.

PAST HISTORY:
H/o Grade 1 hepatic encephalopathy (resolved) secondary to alcoholic liver disease with Pre renal AKI(resolved) 4 months back
 H/o CVA 3 years back
K/C/O HTN since 3 yrs

PERSONAL HISTORY: 
Mixed diet
Normal appetite
Normal bowel and bladder habits
Addictions: drinks alcohol daily of 360 ml for 30 years and stopped 5 months back
 Smokes daily of 1 pack for 30 years, stopped 5 months ago
O/E: Patient is c/c/c
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema


VITALS: 
Temp: afebrile
BP: 140/80 mm hg
PR: 52 bpm
Spo2: 97% at RA
RR: 16 cpm
GRBS: 112 mg/dl
CVS: S1S2 Heard
RS: BAE Present
P/A: Soft, non-tender, bowel sounds heard

CNS:                     R          L
Tone- UL            N         Hypotonic
            LL            N        Hypotonic
 Power-UL         4/5    3/5
             LL          4/5    3/5
 Reflexes- Biceps- +1   -
                 Triceps- +1    -
                 Supinator- +1  
                 Knee-      +1    -
                 Ankle-.   +1       -
                 Plantar- flexion extension

Investigations:












 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


Treatment:

Inj.. OPTINEURON in 100 ml NS IV/OD

Inj. THIAMINE 200 mg in 100ml NS IV BD

Tab. ECOSPIRIN-GOLD 20mg PO OD

Tab. PANTOP 40 mg PO/OD

Tab. TELMA 40 mg PO/OD

Physiotherapy of left UL&LL

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