50 Year Old Man with Weakness in Lower Limbs

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.



This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.


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.

Ankur Kumar
Roll no 14


A 50year old male patient from naryanapuram Presented to casualty(29-06-22)with the chief complaint of giddiness and weakness in both lower limbs since afternoon.              


HOPI:

Patient was apparently asymptomatic 1day back then he developed headache and dizziness for 30min on and off in the early morning but still he went to perform his daily work activities (i.e.agriculture) from the afternoon then he progessed to deviation of mouth towards right side with giddiness and weakness in both lower limbs.
He also has pain in the right side of the face
H/o of vomiting (3episodes) which was non bilious and non projectile since morning 

From today morning there is difficulty in walking i.e swaying on right side
 H/o slurred speech, 
No h/o urinary incontinence,
No h/o loss of consciousness (to rule out brainstem involvement)
No h/o transient loss of vision (to rule out TIA)
no h/o fever, night sweats, weight loss
No h/o head /spine trauma
No h/o involuntary movement
No h/o palpitations and sob 
No h/o double vision (3,4,6 cranial nerve)
No h/o tinnitus(8th cranial nerve)
No h/o difficultly in swallowing ,nasal regurgitation,hoarsness of voice (9,10)
No h/o altered sensorium and behavioural changes

Daily routine 
The patient wakes up at around 4 am and completes his daily morning activities. He is farmer  by occupation  At around 9:00am he goes back to work and come back home at around 6 pm. He has food and sleeps by 9 pm.

Past history:
H/o hypertension from the past 4 years
No h/o diabetes, asthma,TB, epilepsy
No similar complaint in the past


Drug history:
He took anti -HTN drug only when he feels anxiety and weakness in the limbs

Family history:no similar complaints in the family

Personal history

Diet:mixed
Appetite: normal 
Bowel and bladder: regular 
Sleep: reduced
Addiction: occasionally he drinks Alcohol

Examination

General examination 

No pallor
No Icterus, Clubbing, Lymphadenopathy ,Edema

Vitals -

BP:150/100(lft arm)
PULSE RATE:82/min
RESPIRATORY RATE:20cycles/min
TEMPARATURE:afebrile


CNS EXAMINATION
Right handed person 

HIGHER MENTAL FUNCTION
Counsious ,oreinted to time place person
Speech normal
Behaviour normal
Memory intact 
Intelligence normal 
Lobar function normal

CRANIAL NERVE EXAMINATION
  -OLFACTORY-normal
 - optic : normal visual field on the right side 
Left side slight reduced vision from childhood due to trauma
 - oculomotor,trochlear,abducens-
 -facial-unable to smile and blow the mouth
 - vestibulocochlear- intact
 - glossopharyngeal -intact
  - vagus-intact
  -accesory spinal ganglion nerve intact
  - hypoglossal intact


Sensory system:
-fine touch: intact
-pain: normal 
-temperature - normal
- vibration -normal
-stereognosis - 
-two point discrimination-present


Motor system examination

Nutrition -

U/L.             R.   . L 
            Normal. Normal
L/L.     Normal. Normal

ANY ATOPHY-

TONE:
      
                             R.                 L.
   
      R/L                Hypotonia.    Normotonia
       
      
      L/L              Normotonia.   Normotonia 



POWER. RIGHT. LEFT.
SHOULDER

 flexion : 5/5 5/5

 Extension 5/5. 5/5

Abduction 5/5. 5/5

Adduction 5/5. 5/5

Internal rotation 5/5. 5/5

External rotation 5/5. 5/5

Elbow:5/5. 5/5

Flexion. 5/5. 5/5

Extension:5/5. 5/5

Wrist:5/5. 5/5

Flexion:5/5. 5/5

Extension:5/5. 5/5

Abduction : 5/5. 5/5

adduction:5/5. 5/5



Hip

Flexion:5/5. 5/5 

Extension. 5/5. 5/5

Abduction:5/5. 5/5

Adduction 5/5. 5/5

Internal rotation:5/5. 5/5

External rotation. 5/5. 5/5



Knee 5/5. 5/5

Flexion 5/5. 5/5

Extension. 5/5. 5/5 

Ankle. 5/5. 5/5

Plantarflexion:. 5 /5. 5/5

Dorsiflexion. 5/5. 5/5

Toe. 5/5 5/5

Movements:5/5



REFLEXES: right left

Corneal present 

Conjunctival present 

Abdominal: present 

Plantar: present 

DEEP REFLEXES:

Biceps : 5+. 5+
Triceps 5+. 5+
Knee : 5+. 5+
Ankle: 5+. 5+
    

CEREBELLAR 

NYSTAGMUS absent
DYSADIADOCHOKINESIA absent 

FINGER NOSE tip- unable to perform






Rhomberg sign pt unable to stand 
Tandem walking 
Pronator drift absent
Rebound phenomenon present
Heel to knee intact
Gait unable to stand

 Meningial sign 
 Kernigs sign negative 
Brudzinski sign negative 
 
Cvs-s1 s2 heard ,no murmur
Respiratory system 
I: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
P: Trachea central, chest expansion normal
P: Resonant
A: B/l equal air entry
B/I VBS
no added sound
Per. Abdominal examination 
I normal
P soft non tender
No organomegaly
P no fluid thrill and shifting dullness
Auscultation:



Investigations
MRI










Ultrasound





ECG

Radiology and Imaging 




Provisional diagnosis
Acute ischemic stroke with infract in right cerebellar hemisphere 


Treatment

Tab .Clopidogrel
 Tab. Ecospirin
Tab .atorvastatin


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