1801006157-LONG CASE
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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.
1801006157
CASE:
A 50 year old male resident of miryalaguda, ice factory worker by occupation came with chief complaints of
Weakness of right upper and lower limbs since 5 days
Slurring of mouth since 5 days
Deviation of mouth since 5 days
HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 month back when he developed weakness and giddiness of right upper and lower limbs followed by fall and was diagnosed with hypertension during the routine checkup and advised to take medication for the same.
Patient then developed sudden onset of weakness in the right upper and lower limb 5 days back sudden in onset observed in the morning while he was going to washroom and he was swaying towards right side and unable to walk, associated with deviation of mouth towards left side and slurring of speech after few minutes and was taken to nearby hospital and where he underwent CT SCAN,then referred to our hospital the next day.
Upper limb- Patient has difficulty in combing hair, difficulty in buttoning and unbuttoning.
Lower limb- not able to stand due to swaying towards right side
No h/o tingling and numbness, patient is able to feel his clothes.
No H/o loss of consciousness, altered sensorium and headache, seizures and bowel and bladder disturbances
No H/o diplopia, blurred vision, drooping of eyelids, able to chew food and no difficulty in swallowing
no history of difficulty in closing eyes , lips, able to sense taste and able to move neck and tongue
No H/o fever, vomiting, headache , neck stiffness or any trauma to the head.
PAST HISTORY:
30 years ago sustained a fracture in the right elbow.
Known case of hypertension since 1 month
Patient started using medication for hypertension for 20days and stopped for next 10days.
No history of diabetes mellitus, asthma, tuberculosis, epilepsy, thyroid abnormalities,coronary artery disease.
PERSONAL HISTORY:-
The patient wakes up at 4:00am in the morning daily. He has tea and goes to work in the ice factory. He lives very close to the ice factory. He comes home and has breakfast at around 8 to 9 am. He usually takes rice and curry for breakfast. He then goes back to work and comes home for lunch at around 2:00 pm. He usually has rice with curry and dal for lunch. He consumes chicken or mutton thrice weekly. He sometimes takes a nap in the afternoon depending on his work for the day. He finishes his work by around 6:00 pm following which he comes home, takes tea and bath. Sometimes he works till 9:00 pm.He sleeps by 9:00 pm.
The patient has been chewing tobacco for around 10 years. 1 packet of tobacco lasts for 2 days.
He consumes alcohol on a regular basis since 30 years. He stopped for around 3 years and started again 6 months ago after the death of his daughter’s husband.
Bowel and bladder movements are regular.
TREATMENT HISTORY:-
He consumed medication for hypertension Amlodipine and Atenolol for 20 days which he stopped around 10 days ago.
FAMILY HISTORY:-
No similar complaints in the family.
GENERAL EXAMINATION:-
Patient is conscious, cooperative, with slurred speech
Well oriented to time, place and person
Moderately built and moderately nourished.
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema
Vitals :-
Temp - afebrile
BP - 140/80 mm Hg
Pulse rate - 75 bpm
Respiratory rate - 16 cycles per minute
SYSTEMIC EXAMINATION:-
1) CNS EXAMINATION:-
RIGHT SIDED DOMINANT
Higher mental functions intact-conscious,coherent,oriented to time place and person.
speech-no aphasia,dysphonia,dysarthria.
Memory- normal
No meningeal signs
No delusions and hallucinations.
Glasgow scale - 15/15
Gait - walks with support
Cranial nerves -
I - no alteration in smell
II - no visual disturbances
III, IV, VI - eyes move in all directions
V - sensations of face are intact,tone of muscles of mastication are normal.
VII - Deviation of mouth to the left side, upper half of right side and left side normal
VIII - hearing is normal,no vertigo and nystagmus.
IX,X - no difficulty in swallowing
XI - neck moves in all directions
XII - tongue movements normal, no deviation
Pupils - both are normal in size, reactive to light
Motor system:
TONE :
Rt Lt
UL Increased Normal
LL Increased Normal
POWER:-
Rt Lt
UL 4/5 5/5
LL 4/5 5/5
REFLEXES:
Rt Lt
Biceps +++ ++
triceps +++ ++
supinator +++ ++
knee +++ ++
ankle +++ ++
plantar extension flexion
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