65M with left sided weakness

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Case history-by Dr.Aditya samitinjay

 A 65 year old man presented to the OPD with a 2 day history of left sided weakness. An able farmer with a chiselled body, the patient was his usual self 2 days ago, and just before going to sleep he wanted to urinate. As he got up from his bed and started walking towards the bathroom, the patient suddenly slipped and fell with a moderate force on his left hip. He immediately felt weakness in his left upper and lower limb. Calling his wife for help, he also noticed that his speech was slurring. His wife quickly checked for any external injuries and helped him to the toilet. He relieved himself and then came back to his bed. The couple immediately called for their daughter who hurried to the scene. Sensing a problem, he however did not seek consultation until this morning when we first noticed him walking with a stick and a left sided limp to our attending table. He denied using a walking stick ever before this incident. The patient says that since birth he had been having a left leg deformity which made him limp when he started walking. He aced his other milestones. He never recieved a formal education and was put into work from a tender age of 11. He recalls being delinquent at that age, when he started smoking beedis and chuttas and consumed cheap liquor at will. He however was a dedicated worker and well received in his community. 

I redirect the conversation to the current incident and the patient reports that his weakness progressed over a few hours. On probing further he says, he has the most difficulty in getting up from a squatting position, standing up from a chair without support, holding a glass, holding his own walking stick with his left hand and a great difficulty in wearing shirts and innerwear. He reports that he has been unable to manage lifting his left arm over his head without the support of the other arm. The weakness stabilised after a few hours from onset. He denies stiffness in his left sided limbs, he denies buckling of his knees. He says his speech has been slurring since this incident. Strikingly, the son is surprised when he himself noticed, the patient's pronunciation of his daughter's name as "Sssuj . . ."  instead of the usual "Suj . . ." . The patient is able to respond well to my questions, with appropriate responses. He denies having loss of smell, double vision or loss of sight. He denies having unusual sensations on his face and a difficulty in chewing food. He denies history of drooping of eyelids or drooling of saliva. He also denied deviation of angle of mouth. So do the attendants. He denied tinnitus or a feeling of imbalance on walking or change in position while sleeping or sitting. No history of change in the timbre of his voice, he denied hoarseness, nasal regurgitation of food and water or a nasal twang to his speech. He is able to swallow well. 

The patient reported that he receives 80,000 INR every 6 months for his work. He recalls that he received his last payment  6 months ago and he is due his latest payment. He says that his work involves ploughing and planting seeds, with a bit of added work involving tending to goats and sheep. A quick question on how he manages his finances is dealt with swiftly by reassuring details. He denies ever being incontinent but adds that he had been having a thin stream of urine with urgency, frequency and occasional hesitancy for the past few months. He recalls that the stream improves with some straining. No history of constipation. The patient swiftly dealt with questions on simple arithmetic, he has an intact right left orientation and has no difficulty in identifying which fingers he uses for his signature and turning in a key for a lock. 

As the interview progressed further, his choice of words, an surpising admixture of colloquial English words with Telugu, reassured us of his language comprehension and understanding. His long term memory is intact as he still remembers events from his childhood in good detail (he confided to us some of his childhood shenanigans). His working and abstract memory were on point. He swiftly identified his walking stick and the stool he sat on, when asked to identify objects.  On some direct questioning, he denied having loss of pain or temperature, gait imbalance or colliding with objects along his way. He denies having a history of fever, headache neck rigidity or photophobia. 

A review of systems reveals a chronic cough for 30 years with a spoonful of transparent and mild mucoid expectoration. He cannot recall having a diurnal or seasonal variation of his cough. He occasionally feels breathless while doing intense work. He denied palpitations, chest pain or feeling dizzy. He also denied wheeze and hemoptysis. 

Father to 3 children, the patient is well supported by them. They appear very concerned. The patient quite proudly reports finishing off 18 beedis in 2 days and the occasional chutta once a week. He religiously consumes 90ml of whiskey everyday. He says they relax him after a hard day's work. He enjoys home cooked home non vegetarian food. He is hoping for a quick resolution and wants to get back to his usual self. 

On examination-

Pt is conscious,coherent and cooperative ,Thin built,well nourished

No signs of- Pallor,icterus,cyanosis,clubbing,koilonychia,lymphadenopathy,pedal oedema 

Vitals-

Afebrile

BP-130/90 mmhg

Pulse-78bpm

R.R-12cpm

CVS-S1,S2 +

R.S -BAE +

P/A-soft, nontender,no organomegaly 

CNS-

He isconscious, oriented to time,place and person

Slurred speech is present

Motor

   Tone-Normal in all four limbs 

    Power-                

       Rt.                       Lt

UL.  

Biceps 5/5.              3/5

Triceps 5/5.             3/5

Wrist.  E 5/5.           1/5

            F. 5/5.           1/5

LL. 

Iliopsoas +4/5.          -4/5

Knee.     E +4/5.         +4/5

               F   +3/5.        +3/5

EHL.            3/5.           3/5

FHL.            3/5.            3/5 

Gluteus.      5/5.           5/5

      Reflexes -

 Deep tendon reflexes

Biceps.      +2             +3

Triceps       +2.             +2

Supinator.   +1            +1

Knee            +2.            +2

Ankle            +2.            +2

    Superficial reflexes -present 

Sensory  

   Vibration sensation are decreased 

Cranial nerves- 

Facial nerve-deviation of mouth to right side,frowning present.

Cerebellar functions - Normal

Investigations-

Day 1

Day 3

Reflexes video:

https://drive.google.com/folderview?id=1VHaXs-AFHUMjCwtfZ5M-7smMXCW_6ElO

Gait video:

Day 1:

Day 2:

 Diagnosis- ? Left Sided Hemiparesis with UMN Type Left Sided Facial Palsy secondary to Ischemic CVA associated with 60 pack years Smoking and Chronic Alcoholism since 50 years.

  Treatment- 

Inj.optineuron I.M

Tab .Aspirin 75mg OD

Tab.Atrovastatin  20mg OD

Tab MVT O.D