73 y/o man with old CVA , k/c/o HTN and recurrent hypokalemia

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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. 

9 November 2023 

Chief complaints - 

Patient came with complaints of  headache since 6 months, giddiness since 10 days, numbness and tingling sensation of both upper limbs and lower limbs since 10 days 

History of presenting illness- 

Patient was apparently asymptomatic 6 months back then he developed headache which was diffuse, insidious in onset , non progressive and for a duration of 30 mins to 1 hr

No h/o blurring of vision, photophobia, vomiting, phonophobia

H/o giddiness present since 10 days which is insidious in onset and diurnal variation present 

H/o dragging type of pain of rt upper limb and tingling and numbness of both upper limb and lower limb from below elbow and below ankle respectively since 10 days 

No h/o polyuria, polyphagia polydipsia, chest pain, palpitations, sob 

No h/o fever, abdominal pain and burning micturition 

Past history - 

K/c/o old CVA - rt hemiparesis 

K/c/o HTN since 2 yrs 

K/c/o recurrent hypokalemia 

USG done in 2019 - diffuse antral gastritis, duodenal ulcer 

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

Personal history - 

Appetite - normal 

Diet - mixed 

Bowel - regular 

Bladder - normal 

No known allergies 

No addictions 

General physical examination 

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

Pallor + 

No icterus, cyanosis, clubbing, lymphadenopathy and pedal edema 

Vitals on admission : 

Temp - afebrile 

BP - 100/60 mm hg 

PR - 70 bpm  

RR- 16cpm 

SpO2 - 98% on RA 

GRBS -  150mg/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 - N

8th CN - decreased hearing in both ears 

9th CN - N  

10th CN - gag reflex - N 

11th CN -  shrugging of shoulder against resistance + 

12th CN -  no deviation of tongue 

Sensory system - normal 

Motor system - bulk - N 

                          tone - decreased in both rt upper limb and lower limb

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

                                     Rt           Lt 

                     B            +             ++ 

                     T            +             ++

                     S            +             +

                     K           +             ++

                     A            +              + 

                 Plantar -    Flexion 

Cerebellar signs - finger nose in-coordination - no 

                             knee heel in-coordination - no 

Biceps reflex

Supinator reflex

Triceps reflex

Knee jerk

Ankle reflex

Plantar reflex

Gait

Provisional diagnosis - 

Old CVA with rt hemiparesis with HTN with COPD 

Investigations- 

Plan of treatment - 

Tab ECOSPRIN AV 75/10 PO OD 

Tab DOLO 650 PO OD 

Tab OMEPRAZOLE 40 mg PO OD BBF 

Tab ULTRACET PO BD 

Tab VERTIN 16 mg PO OD 

Tab AZITHROMYCIN 500 mg PO OD 

Tab PREGABA M 75 /10 PO HS 

Tab MVT PO OD 

Nebulisation with DUOLIN TID 

Tab ACEBROPHYLLINE 100mg PO BD 

Syp GRILLINCTUS 10 ml PO BD 

Syp ARISTOZYME 10ml PO BD