65 y/o male with Rt hemiparesis

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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. 

8 November 2023 

A 65 year old male came to the opd with chief complaints of weakness and tingling sensation in right upper limb and lower limb since 4 yrs and increased frequency of micturition since 1 month 

History of presenting illness - 

Patient was apparently asymptomatic 4 yrs back then he developed weakness and tingling sensation in right upper limb and lower limb which is sudden in onset and non-progressive in nature. Pt was unable to get up from bed and was taken to Suryapet hospital and was diagnosed to have left basal ganglion bleed. 

CT REPORT DATED Jan 2019 

C/o numbness and tingling sensation in rt upper limb and lower limb involving proximal muscles.

C/o increased frequency of micturition since 1 month.

No h/o deviation of mouth, slurring of speech, involuntary movements, squinting of eyes, facial muscle weakness, involuntary bowel and bladder movements. 

No h/o fever, cough,nausea, vomiting, diarrhoea, sob, palpitations 

Past history - 

Patient is k/c/o hypertension since 4 yrs on tab ENALAPRIL 2.5mg 

N/k/c/o DM, TB, asthma, epilepsy, CAD, thyroid disorders 

H/o tibia fracture 6 months ago for which underwent surgery 

Personal history - 

He is a farmer by occupation 

Appetite - normal 

Diet - mixed 

Micturition- increased 

Bowel - regular 

No known allergies 

No addictions 

Family history - 

No significant family history 

General physical examination - 

Patient is conscious, coherent and cooperative and well oriented to time, place and person 

No pallor, icterus, cyanosis, clubbing, lymphadenopathy and pedal edema 

Vitals on admission : 

Temp - afebrile 

BP - 140/90 mm hg 

PR - 86bpm 

RR- 16cpm 

SpO2 - 98% on RA 

GRBS -  97mg/dl 

Systemic examination - 

CVS : S1, S2 heard; no murmurs 

RESP SYS : trachea central, B/l air entry +, NVBS heard, no added sounds 

P/A : soft, non tender, no organomegaly 

CNS : 

GCS - E4V5M6 

Higher mental functions - intact 

Cranial nerves - 

1st CN - sense of smell - N 

2nd CN - vision - intact 

3rd, 4th and 6th CN - extra-ocular movements - N 

5th CN - decreased sensations on right side of face 

               numbness of tongue and decreased sensation of taste 

8th CN - hearing and balance - N 

9th CN - decreased taste sensation , pharyngeal reflex - N 

10th CN - gag reflex - N 

11th CN -  shrugging of shoulder against resistance + 

12th CN -  no deviation of tongue 

Sensory system - decreased sensation on both rt upper and lower limb extending upto abdomen 

Motor system - bulk - N 

                          tone - N 

                          power - decreased in both rt upper and lower limb 4/5 

                                     Rt           Lt 

                     B            +             ++ 

                     T            +             ++

                     S            +             ++ 

                     K           +             ++

                     A            +              + 

                 Plantar -     Mute on both sides 

Cerebellar signs - finger nose in-coordination - no 

                             knee heel in-coordination - no 

Provisional diagnosis - 

Old hemorrhagic stroke of left basal ganglia with HTN 

Investigations - 

Treatment - 

Tab ENALAPRIL 2.5 mg PO OD 

Tab PREGABA M 75 mg PO OD 

Tab SHELCAL 500 mg PO OD