60 year old with weakness in the left upper and lower limb

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I’ve 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. 

 A 60 year old male, farmer by occupation and a resident of nalagonda came with the chief complaints of 

• Weakness in the lower limb since 2 days 
• Weakness in the upper limb since 2 days 
• Slurring of speech since 2 days. 

History of presenting illness :

The patient was apparently asymptotic 2 days back. He woke up at 5:00 and did his daily routine. Then he went to milk the buffalo. While he was half way through his work he felt a sudden weakness in the left upper and lower limb; it was sudden in onset with inability to use the left hand. Slurring of speech was also noticed. 

Past history:

There were no similar episodes in the past. 

He was not diagnosed with hypertension, DM, bronchial Asthana, epilepsy, CAD. 

Personal history 

Appetite : normal 

Diet : mixed 

Bowel and bladder: regular 

Addictions: he is consumes alcohol occasionally. (During festivals - 90ml). He does not smoke 

General examination: 

The patient is conscious, coherent and cooperative. He is moderately built and moderately nourished. 

No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema were seen 

Vitals: 

BP: 130/80mm of hg

PR: 75bpm

Temperature: afebrile 

Respiratory rate: 14cmp 

Systemic examination: 

CNS: 

Cranial nerve examination: 

Right and left cranial nerves 1-10 were intact 

On examination for the cranial nerve 11 ( shrugging of shoulders) the patient was unlable to shrug his left shoulder.

On examination for cranial nerve 12 (protrusion and tongue and it’s movements) : deviation of the tongue to the left side was noticed. 

Motor examination: 

Upper limb: 

                                  Right                      Left 

Tone:                   Normal                    Hypertonic 

Power :         

Biceps                      5                                 4

Triceps                     5                                 4

Supinator                 5                                  1

Palmar interossei     5                                  1

Dorsal interossei      5                                  1

Lumbricals  

Reflexes 

Biceps                   2+                           3+

Triceps                  2+                           3+

Supinator              2+                            3+

Lower limb

Tone                  Normal                  Hypertonic 

Power                    5                                4

Knee                      2+                             3+

Ankle                    2+                              3+

 

: Respiratory system examination

Bilateral air entry was present. 

Normal vesicular breath sounds were heard. 

CVS: 

S1 and S2 are heard. 

No abnormal heart sounds were heard. 

Per abdominal examination: 

Abdomen was soft and tender. 

No organomegaly was noticed.