55 yr old male with deviation of mouth since 2 days and right knee pain since 2 days

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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, investigations and come up with diagnosis and treatment plan.

 CASE PRESENTATION:

Patient came to the opd on 8/8/23 with:

C/O deviation of mouth to left side since 2 days

C/O dizziness and nausea since 2 days

C/O Right knee joint pain 

Patient was apparently aysmptomatic 2 days back then he developed deviation of mouth to the left side which lasted for 1 day and then it became normal after getting treated by a local RMP. 

Then he was brought to the hospital by his attenders with C/O Right upper thigh spasm

No h/o weakness, trauma

No restriction of movements

Pain aggravated on walking , and radiating from right hip to right toe. 

No h/o drooling of saliva

No loss of forehead wrinkles

Since 1 days the patient is complaining of RT knee joint pain with swelling.. He is unable to walk due to severe pain. 

Patient previously had 5 similar episodes of knee pain in the last 5 months

PAST HISTORY:

K/C/O HTN since 12 yrs on T. Telmisartan, T. Clinidipine, T. Metoprolol 40mg/10mg/47.50mg

K/C/O DM II since 11 yrs on T.GLIMIPERIDE 2mg, T.VOGLIBOSE 0.2mg, T.METFORMIN 500mg

H/O abscess drainage on left buttock 1 year ago

PERSONAL HISTORY:

Patient is stone breaker by occupation

Diet:  Mixed

Appetite: Normal

Sleep: Adequate

Bowel and bladder habits:  passing hard stools since 12 days

Addictions: 

Consumes toddy since  stopped 2 days ago

FAMILY HISTORY:    Insignificant

GENERAL EXAMINATION:

Patient is conscious, incoherent, non-cooperative

 No pallor, icterus, clubbing, cyanosis, lymphadenopathy, edema

VITALS:

PR : 84 bpm

BP: 160/90 mmHg

RR: 16 cpm

SYSTEMIC EXAMINATION:

CVS: S1S2 heard, no murmurs

RS: BLAE+, NVBS

P/A: soft,non tender

CNS: 

Higher mental functions :intact

Motor examination:

Tone.         Rt.                 Lt 

      UL.        N                  N

       LL.        N                  N

Power    

        UL.      5/5              5/5

        LL.       4/5              5/5

Reflexes 

         B.         2+               2+

         T           2+               2+

          S           1+              1+

          K  Pain on flexion  2+

          A.           -                  -

          P       Flexion       Flexion

Dysdiadokinesia: negative

Finger nose and finger finger in coordination: negative

Rhomberg’s test: negative

EXAMINATION OF RT KNEE JT:

SLRT: 30 in right leg

Skin- Normal

Swelling- present diffusely around the Rt knee joint 

Tenderness- Diffuse around the knee jt

Deformity- Mild FFD

Patellar tap- present

Crepitus: +

ROM: painful and restricted 

Local rise of temp+

Distal pulses +

INVESTIGATIONS:

Xray B/L knee :

USG RT. KNEE :

MRI brain:

Chest xray:

ECG:

DIAGNOSIS:

ACUTE CVA WITH ACUTE INFARCT IN BODY OF RT CAUDATE AND RT CORONA RADIATA WITH RT KNEE GOUTY ARTHRITIS

TREATMENT:

1.T.ECOSPIRIN GOLD PO/HS 75/75/10

2.T.TELMISARTAN + T. CLINIDIPINE + T. METOPROLOL 40MG/10MG/4.5MG

3.T.GLIMIPERIDE + T. VOGLIBOSE+ T. METFORMIN 2MG/0.2MG/500MG PO/OD