65yr old male with Weakness of limbs on Right side and slurred speech

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 A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT .

Rollno.61

Aruna.J

Case Report:

A 65YR old male resident of Nalgonda a retired farmer by occupation with Chief complaints of slurred speech and weakness of Right upper and lower limb since 3 days.

HOPI:

Patient was apparently asymptomatic 5yrs ago.

Patient was asymptomatic 5 yrs back when he had  Right flank pain radiating to groin, fever, weakness and polyuria and went to hospital and was diagnosed with CKD . He also complains of SOB on exertion since past 5 years.

He Had  10 rounds of dialysis for 2 years but then he was advised to stop the dialysis and was normal without dialysis since 2 years.

H/O trauma to right foot 1 month back which was left untreated and has black discoloration with foul smelling discharge.

On 4th Aug, he had tingling sensation of Right Upper limb and lower limb and when he was walking he slipped and fell down, came home and felt  weakness of his Right upper limb and Lower limb and slurring of speech 2 hrs later. He was observed and when bp was checked by  RMP it was 220/100 and some antihypertensives were given and next day he was brought to our hospital for further management.

PAST HISTORY:

He is a known case of DM since 3 years and is on insulin.

Hypertension diagnosed 4 days back when he came to the hospital and is on medication.

No H/O - Asthma, T.B, Epilepsy, Thyroid disorders and CAD.

Daily Routine- He wakes up at 6 am in the morning has tea goes to visit his fields at 7am and returns home at around 11 am and has lunch at 12pm  then rests and  has tea at 4pm in the evening goes for a walk later for 20min. He has dinner at 8pm and sleeps around 9:30pm.

Family History - Not similar complaints in family.

Personal History-

Diet:- Mixed.

Appetite - Normal 

Sleep:- adequate

Bowel and bladder:- regular

Addictions :- 

Alcohol occasionally

Smoking since past 30yrs 1 pack /day. Stopped from last few days.

No known drug and food allergies

The patient underwent cataract surgery of Right eye in the past.

GENERAL EXAMINATION-

He is conscious coherent and cooperative.

Moderately built  and moderately nourished. 

Pallor- Absent 

Icterus- Absent

Cyanosis- Absent

Clubbing-Absent 

Lymphadenopathy - Absent

Edema-Absent.

Vitals-

Temp- Afebrile.

Pulse-76bpm

RR- 18cpm

BP- 160/90 mm Hg.

SYSTEMIC EXAMINATION:

CNS-Right Handed person.

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

MMSE- 

speech : Slurred

Behavior : normal 

Memory : Intact.

Intelligence : Normal

Lobar Functions : Normal.

No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:CNS:

1st : Normal

2nd : visual acuity is normal and   visual field is normal                 

3rd,4th,6th : Pupillary reflexes present in Right Eye and cannot fully be appreciated on the left.

 EOM full range of motion present                   

5th : sensory intact

       motor intact

7th : normal

8th : No abnormality noted.

9th,10th : palatal movements present and equal.

11th,12th : normal.

MOTOR EXAMINATION: Right Left

                                           

  BULK-

Right and left - UL LL bulk is normal.

   TONE 

Right-

UL - hypotonia

LL-hypotonia

Left -

UL and LL - Normal 

   POWER 

Right side

UL- 0

LL 0

Left -

UL -5/5

LL-5/5

   SUPERFICIAL REFLEXES:

   CORNEAL present present       

   CONJUNCTIVAL present present

   ABDOMINAL present

   PLANTAR - Extensor withdrawal.

  DEEP TENDON reflexes -HMF INTACT

         

                    UL. LL

Tone RT. Hypo. N

           LT. Hypo. N

Power RT. 0/5. 4/5

            LT. 1/5. 4/5

Reflexes. Rt. Lt

                B. - couldn't be elicited 

                T. +. ++

                S. +. +

                K. ++. ++

                A. -. -

                P Extensor withdrawal

 

  

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

 Intact on Both sides.

Crude touch

pain

temperature

DORSAL COLUMN SENSATION: Intact on Both sides

Fine touch

Vibration

Proprioception

CORTICAL SENSATION: Present on both sides

Two point discrimination

Tactile localisation.

steregnosis.

CEREBELLAR EXAMINATION:

  Finger nose test - Performed with left hand and is normal.

 Dysdiadochokinesia-   could not be performed since he is unable to move right hand.

  Hypotonia

  Intention tremor ABSENT

  Nystagmus-Absent

  Speech - Slurred

  Rhombergs test -Cannot be performed.

SIGNS OF MENINGEAL IRRITATION: absent

GAIT:unable to walk since  he cannot move his right upper and lower limbs

RESPIRATORY SYSTEM

Inspection: 

Shape of chest: Normal

No scars and sinuses 

Trachea central

Palpation:

Inspectory findings are confirmed

Palpable sounds felt.

Auscultation :

Ronchi and crepts are heard.

PER ABDOMEN

Inspection:

No abdominal distension

No scars, sinuses, masses visible

Umbilicus slit like.

Palpation:

No organomegaly

Inspectory findings are confirmed 

No Tenderness

Auscultation: Normal bowel sounds heard

No bruit heard

CARDIOVASCULAR SYSTEM:

Inspection : 

No scars, sinuses

No visible pulsations

Palpation:

Inspectory findings are confirmed

Apex beat normal

On Auscultation : 

S1 S2 heard .

No murmurs or additional heart sounds 

Provisional Diagnosis-

 Right Hemiparesis secondary to stroke.

Type 2 DM ,HTN and H/O CKD.

Investigations-

ECG

2D Echo:

Treatment