50 yr old male with left Upper Limb& Lower Limbs weakness

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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, and investigations, and come up with a diagnosis and treatment plan.

CASE PRESENTATION

Patient came with complaints of Weakness of left upper and lower limb since today morning. 

Slurring of speech since today morning

Deviation of mouth towards right side since today morning. 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 1 day back then he developed tingling and burning sensation of left upper and lower limbs for which he went to RMP doctor and was given unknown medication, which relieved the tingling sensation.

Today morning he noticed that he is unable to get up from bed due to weakness of left upper and lower limbs,deviation of mouth to right side, slurring of speech.

No h/o LOC, giddiness, neck stiffness

No c/o weakness, disphagia 

No h/o seizures

H/o giddiness and fall from the bike 3 years ago and diagnosed as denovo HTN and CT scan was done(was told to have clots in brain)

Had h/o ?memory disturbances 3 years back

PAST HISTORY:

H/o Grade 1 hepatic encephalopathy (resolved) secondary to alcoholic liver disease with Pre renal AKI(resolved) 4 months back

H/o CVA 3 years back

K/C/O HTN since 3 yrs(on Tab. TELMA 40mg PO/OD)

PERSONAL HISTORY:

Mixed diet

Normal appetite

Normal bowel and bladder habits

Addictions: drinks alcohol daily of 360 ml for 30 years and stopped 5 months back

Smokes daily of 1 pack for 30 years, stopped 5 months ago

O/E: 

Patient is c/c/c

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, pedal edema. 

VITALS:  

Temp: afebrile

BP: 140/80 mm hg

PR: 52 bpm

Spo2: 97% at RA

RR: 16 cpm

GRBS: 112 mg/dl

CVS: S1S2 Heard

RS: BAE Present

P/A: Soft, non tender, bowel sounds heard

CNS:                     R          L

Tone- UL            N         Hypotonic

            LL            N        Hypotonic

 Power-UL         4/5    3/5

             LL          4/5    3/5

 Reflexes- Biceps- +1   -

                 Triceps- +1    -

                 Supinator- +1  

                 Knee-      +1    -

                 Ankle-.   +1       -

                 Plantar- flexion extension

INVESTIGATIONS:

DIAGNOSIS: 

Acute ischemic CVA with left UL and LL hemiparesis(Late hyperacute infarct in Right PONS, chronic infarct in Right and Left Frontal and Right occipital)

HTN since 3 years

TREATMENT:

Inj. OPTINEURON in 100 ml NS IV/OD

Inj. THIAMINE 200 mg in 100ml NS IV BD

Tab. ECOSPIRIN-GOLD 20mg PO OD

Tab. PANTOP 40 mg PO/OD

Tab. TELMA 40 mg PO/OD

Physiotherapy of left Upper Limb and Lower Limb