70M with Inability to walk and difficulty speaking

Hello all this is K .Rohit ,a eighth semester student.This E Log depicts the patient centered approach to learning

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.

A 70 yr old male came to OPD with chief complaints of difficulty in speech and inability to walk since 2 years 

HOPI 
Patient was apparently asymptomatic 2 years back.He then developed difficulty speaking and inability to walk aggravated in past 6 months 
H/o difficulty in swallowing liquids>solids
No c/o deviation of mouth  
No h/o  SOB,chestpain
No c/o seizures  
No h/o vomitings 

Past history
K/c/o hypertension 18months 
Used medication for 2 months and stopped (telma 20mg)
Not a k/c/o DM,CVA,TB,Epilepsy,CAD,asthma,
H/o of head injury 5years back 

Personal history  
Diet : mixed 
Appetite : normal
Bowel :regular 
Bladder : normal 
Sleep : Adequate 
Addictions : alcohol- regular (stopped 6 yrs back )
Smoking (stopped 6 yrs back )

General examination 
Patient is conscious coherent and cooperative 
Moderatly built 
No signs of pallor, icterus, cyanosis, clubbing, lymphadenopathy,edema
Lipoma present on back side of the neck 

VITALS 
PR :86bpm 
Bp:150 /90mmHg

Systemic examination 
RS: BAE+ NVBS+ 
No added sounds
CVS S1S2 + no murmurs
P/A : soft nontender
CNS : 
Conscious 
Slurred speech 
Cranial nerves intact
Sensory : normal 
Motor:-
Tone :
               Right         left 
UL              N              N 
LL               N             N
Power:
UL             5/5          5/5 
LL             5/5          5/5 
Reflexes :
Biceps       +2           +2
Triceps      +2           +2
Supinator   +              + 
Knee           +3           +3
Ankle          +2           +2
Plantar      flexion   flexion  
No cerebellar signs 
GAIT: SLOW,SHUFFLING
 
INVESTIGATIONS 
2D Echo 
USG 
MRI
ECG  
PROVISIONAL DIAGNOSIS 
Dysathria secondary to chronic infarct in left corona radiata 

Treatment 
Tab Ecosprin AV  75/10 Po/Hs
Tab Amlodipine 5 mg po/OD
Tab MVT po/OD

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