40 year old male with weakness in left upper and lower limbs

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40 YEAR OLD MALE WITH WEAKNESS IN LEFT UPPER AND LOWER LIMBS

A 40 year old male patient,  tyre puncture repair worker by occupation,  hailing from Tirumalagiri,  came to the GM OPD with chief complaints of :

‐ Giddiness

‐ Weakness of left upper and lower limbs

6 days ago

HISTORY OF PRESENT ILLNESS: About 6 days back, when the patient was doing his normal routine daily work,  he had a sudden onset of giddiness with weakness and paresthesia in his left upper and lower limbs. He also developed slurring of speech at that time.

For the past 6 days, the patient also complaints of :

‐ Double vision ( which is binocular diplopia as his vision becomes normal when one of his eye is closed ).

‐ Hyperacussis ( perceives small soft noises as loud noises ) .

‐ Difficulty in swallowing 

‐ Aural fullness in both the ears

PAST HISTORY:  

Patient had history of polio since he was 6 months of age and used to walk on bilateral upper limbs since then.

The patient has history of hypertension since 2yrs for which he has been using Telmisartan 40mg tablet.

He has no history of DM, HTN, TB, epilepsy,  asthma. 

PERSONAL HISTORY : The routine daily life of the patient 6 days back when he was completely normal :‐

The patient used to wake up at 4am in the morning,  get ready, have breakfast and goes to work around 10:30 am. He has his lunch around 2pm and again leaves for work. He then has his dinner at 8pm and then goes to bed.

Diet ‐ mixed

Appetite ‐ normal

Sleep ‐ adequate 

Bowel and Bladder movements ‐ regular 

Addictions ‐ drinks 90ml of alcohol per day since 20 years .

GENERAL EXAMINATION : The patient is conscious , coherent,  cooperative,  well nourished and built. 

Vitals :

Temperature ‐ afebrile

BP - 150/90 mm Hg

RR ‐ 12 cpm

PR ‐ 86 bpm

SYSTEMIC EXAMINATION :

CVS ‐ S1, S2 heard, no murmurs 

RS - BAE+, NVBS heard 

P/A - soft, non tender, no organomegaly,  no distension,  bowel sounds heard

CNS -

Well oriented to time ,place ,person.

Speech: slurred

Cranial nerves : 

6 - Right lateral rectus palsy 

8 - left side air conduction more than bone conduction ( Rinne’s)

Weber’s- patient cannot confirm the lateralisation 

9- deviation of uvula to right side 

Rest of the cranial nerves are normal. 

Motor system :

Tone ‐ B/L UL ‐ normal 

            B/L LL ‐ flaccid

Power ‐ Left UL ‐ 4/5

              Left LL ‐ 2/5

              Right UL ‐ 5/5

              Right LL ‐ 2/5

Power of biceps :

Power of triceps :

Cerebellar tests :

Finger Nose test ‐ normal

Finger Finger test ‐ normal

Dysdiadokokinesia ‐ can be performed 

Gait : cannot be elicited. 

INVESTIGATIONS :

Provisional diagnosis:

Left hemiparesis secondary to acute infarct in right pons secondary to hypertension .

TREATMENT:

1. Inj. Thiamine 1 amp in 100ml NS IV

2. Inj Pantop 40mg IV/OD

3. Tab Vertin 16mg

4. Tab Telma 40mg

5. Tab Ecospirin 75mg

6. Tab Atorvas 40mg 

7. Physiotherapy of left upper and lower limbs