40Y M with b/l upper and lower limb weakness

A 40 year old male patient with slurred speech and weakness of B/l upper and lower limbs

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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.


CASE:

A 40 year old male patient came to the casualty complaining of slurred speech and and weakness of bilateral upper and lower limbs.

History of presenting illness:

Patient was apparently asymptomatic 6 years back then he had slurred speech and paralysis of right hand and deviation of mouth to the left, and diagnosed with CVA and got treated in a local hospital and used some herbal medication for the same for 3 years and stopped. He is apparently alright since then.5 days back he had vomitings for 2 days (7 to 8 episodes per day) food as content for which he was treated in a local hospital. 

Yesterday night on 4/7/2023 he again developed slurred speech and weakness in bilateral upper limbs and  lowerlimbs due to which he is unable to walk and got admitted in local hospital  where they have  diagnosed  them with CVA.


Past history:

Patient is a known case of CVA

Not a known case of Hypertension, DM, asthma epilepsy, CAD 


Personal history:

Diet-mixed 

Diet-mixed 

Appetite-normal 

Sleep-adequate 

Bowel and bladder movements-regular 

Addictions- alcohol intake since 30 years (90ml),decreased consumption since 6 years alcohol intake 10 days back. Tobacco chewing since 30 years.


Family history:

Not significant 


General examination:

Patient is conscious,coherant, cooperative 

Moderately nourished and ill built .

No pallor,Icterus, cyanosis,  clubbing lymphadenopathy, edema


Vitals:

Afebrile

BP-140/70mmhgP8

PR-80bpm

RR-20cpm

Grbs-977mg/dl


Systemic examination:

Central nervous system:

Oriented to time,place,person

Speech: slurred

Cranial nerves: 

1-intact

2- vision: normal

3,4,6- normal(no restriction of movements of eye)

5-normal( muscles of mastication+sensations of face)

7- buccinator weak on left side, deviation of mouth to Right.

8- didn't elicit

9,10,11,12-normal


Motor- tone -normal

Power- upper limb           lower limbs 

Right        4/5                             5/5

Left           3/5                            -4/5


Reflexes :

biceps:             3+                       3+

Triceps.             3+.                     3+

Supinator.          3+.                    3+

Ankle.                2+.                     2+

Knee.                 3+.                    3+


Psychiatry referral done i/v/o alcohol dependence:

Treatment:

1.patient and od were counseled and psychoeducated

2.Harmful effects of substances explained to patient and od.

3. Tab pregabalin 75mg   x-------x------1

4. Tab. Benfothiamine 100mg    x-------1-------x

5. Nico gums 2mg/SOS 


 

Investigations:

CBP:

Haemoglobin 13.9gm/dl

TLC:8,100cells/cu mm

Platelet:2.02 lakhs/cumm 


RFT :

S. Creat: 1mg/dl

Blood urea: 23mg/dl

Na: 139

Cl:101

K:4


LFT:

T. Bilirubin:1.14

D. Bilirubin:0.33

ALP: 141

AST:17

Albumin: 3.7


Rbs:110

Hba1c: 6.5g%

TREATMENT GIVEN:

1. Inj. THIAMINE 200 mg Iv/stat

2. Tab. ASPIRIN 75 mg +CLOPIDOGREL 75 mg +ATORVASTATIN 20mg po/hs 9 pm 



ADVISE AT DISCHARGE:

1.Tab. ECOSPRIN GOLD (75,75,20mg) po/hs 9 pm 

2. Tab pregabalin 75mg   x-------x------1

3.Tab. Benfothiamine 100mg    x-------1-------x

4. Nico gums 2mg/SOS 


FOLLOW UP :

Review after 2 weeks to General medicine op and psychiatry op



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