27 year old male with right sided weakness

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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.

A 27 year old male resident of choutuppal tractor driver by occupation came to GM opd with chief complaints of weakness in right upper and lower limb since 1 day.

Patient was apparently asymptomatic 1 day back when he experienced 2 episodes of giddiness not associated with loss of consciousness not associated with palpitations following which he observed weakness in right upper and lower limb. Sudden in onset, non-progressive from past 1 day. Both limbs were affected at the same time. He is not able to button his shirt or lift his hand above head level, he is able to slip his toes into slippers and squat. There is slight deviation of angle of mouth to the left side and slurring of speech is there from 1 day. No neck stiffness is observed, no trunk involvement is seen. No difficulty in breathing, there is no diurnal variation in weakness of muscles. No involuntary movements are observed, sensations are intact. No H/o loss of consciousness, delusions, hallucinations. There is no rolling over of eyes, drooping of eyelids or restriction in movement of eyes, he is able to feel taste, has sensation over face, no difficulty in hearing, able to move neck in all direction, he is able to roll over his tongue, no unsteadiness in walking, no H/o involuntary micturition or defaecation, no H/o fever, headache, vomiting or diarrhoea.

PAST HISTORY

No similar complaints in the past
He had 2 episodes of seizures once at 8 years and once at 24 years of age it was followed by loss of consciousness for one and half hour.
At the first he used relevant medications for 2 years
No H/o Diabetes, hypertension, coronary artery disease, Tuberculosis

PERSONAL HISTORY

Diet: Mixed
Sleep: Adequate
Smoking: Tobacco for 3 years
Alcohol: From 4 years weekly 3 to 4 times and he drinks 180ml every time he drinks
Bowel and bladder movements: Regular

FAMILY HISTORY
No similar complaints in the family

GENERAL EXAMINATION

Patient is conscious, comfortable, and coherent
Well built and nourished
No pallor, no icterus, no cyanosis, no clubbing, no lymphadenopathy, no pedal edema

VITALS

Temperature: 96.8F
Pulse rate: 122bpm
Respiratory rate: 18cpm
Blood pressure: 200/140 mmhg

CARDIOVASCULAR EXAMINATION

S1, S2 heard, no murmurs

RESPIRATORY SYSTEM

Chest symmetrical, normal vesicular breath sounds heard

ABDOMEN

Abdomen is soft, non-tender, no organomegaly

CENTRAL NERVOUS SYSTEM

Higher mental functions: Intact
Cranial nerves: Normal

CRANIAL NERVE	TEST	RIGHT	LEFT
I	Sense of smell	Intact	Intact
II	i) Visual acuity – Rosenbaum Chart ii) Field of vision – Confrontation test iii) Colour vision – Ishihara chart iv) Fundus	20/20 Normal Normal Normal	20/20 Normal Normal Normal
III, IV, VI	i)               Extra-ocular movements ii)             Direct Light Reflex iii)           Consensual Light Reflex iv)            Accommodation Reflex v)              Ptosis vi)      Nystagmus vii)    Horners syndrome	full Present Present Present Absent Absent No	full Present Present Present Absent Absent No
V	i) Sensory -over face and buccal mucosa ii) Motor – masseter, temporalis, pterygoids iii) Reflex a.     Corneal Reflex b.     Conjunctival Reflex	Normal Normal   Present Present	Normal Normal   Present Present
VII	i) Motor – nasolabial fold hyeracusis occipitofrontalis orbicularis oculi orbicularis oris buccinator platysma ii) Sensory – Taste of anterior 2/3rds of tongue(salt/sweet) Sensation over tragus iii) Reflex – Corneal Conjunctival iv) Secretomotor – Moistness of the eyes/tongue and buccal mucosa	Present Absent Good Good Good Good Good   Normal   Normal   Present Present   Normal	Present Absent Good Good Good Good Good   Normal   Normal   Present Present   Normal
VIII	i) Rinnes Test ii) Webers Test     iii) Nystagmus	Positive Not lateralised   Absent	Positive       Absent
IX, X	i) Uvula, Palatal arches, and movements       ii) Gag reflex iii) Palatal reflex	Centrally placed and symmetrical   Present Present	Present Present
X1	i) Trapezius ii) sternocleidomastoid	Good Good	Good Good
XII	TONGUE i) Tone ii) Wasting iii) Fibrillation iv) Tongue Protrusion to the midline and either side	Normal No No Normal	Normal No No Normal

MOTOR SYSTEM

TEST	RIGHT		LEFT
I – BULK a.     Inspection b.     Palpation	Normal Normal		Normal Normal
II – TONE a.     Upper limbs b.     Lower limbs	Normal Normal		Normal Normal
III – POWER a.     Neck muscles b.     Upper limbs c.     Lower limbs	Good 3/5 4/5		Good 5/5 5/5
IV – REFLEXES A.    SUPERFICIAL REFLEXES 1.     Corneal 2.     Conjunctival 3.     Pharyngeal Reflex 4.     Palatal Reflex   B.    DEEP TENDON REFLEXES 1.     Biceps jerk 2.     Triceps jerk 3.     Supinator jerk 4.     Knee jerk 5.     Ankle jerk	Present Present Present Present     Absent Absent Absent Absent Absent		Present Present Present Present     Present Present Present Present Present
V – COORDINATION TESTED ALONG WITH THE CEREBELLUM	Normal	Normal
VI – GAIT	Normal
VII – INVOLUNTARY MOVEMENTS A – Athetosis, Asterexis B – Ballismus C – Chorea D – Dystonia E – Essential tremors F – Fasciculations M - Myoclonus	Absent Absent Absent Absent Absent Absent Absent

 

SENSORY SYSTEM

TEST	RIGHT	LEFT
I – SPINOTHALAMIC 1.     Crude touch 2.     Pain 3.     Temperature II – POSTERIOR COLUMN 1.     Fine touch 2.     Vibration 3.     Position sense 4.     Romberg’s sign III – CORTICAL 1.     Two point discrimination 2.     Tactile localisation 3.     Graphaesthesia 4.     Stereognosis	Normal Normal Normal   Normal Normal Normal Absent   Normal Normal Normal Normal	Normal Normal Normal   Normal Normal Normal Absent   Normal Normal Normal Normal

 

CEREBELLAR SIGNS

1.     Gait: Normal

2.     Nystagmus: Absent

3.     Hypotonia: Absent

4.     Rebound phenomenon: Absent

5.     Coordination

a.     Upper Limbs –Able to do Finger Nose test, Finger Finger Nose test, Drawing a circle, Putting a dot in the centre of the circle

b.     Lower Limbs – Able to do Heel Knee test, Drawing a circle

c.     Dysdiadokokinesia – Able to do

 

SIGNS OF MENINGEAL IRRITATION

No neck stiffness

No Kernig’s sign

No Brudzinski’s sign 

 

EXAMINATION OF THE SPINE AND CRANIUM

No spinal and cranial deformities

 

PERIPHERAL NERVES

No thickened nerves

No trophic ulcers

No wrist drop

No foot drop

 

CAROTID PULSES AND BRUIT – Absent

 

DIAGNOSIS

Acute ischaemic stroke with right hemiparesis

 

INVESTIGATIONS

Carotid doppler sonography

 

MRI Brain plain

 

Ultrasound

 

Colour doppler 2D echo

 

ECG

 

TREATMENT

T.Ecosprin

T.Clopitab

T.Nicardia

T.Atorvas