55 year old male with hemiplegia

Jan 03 2023
01,2023This 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 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.
CASE-
A 55yr old male came with the chief complaints of burning sensation in left leg since 15 days.
Associated with right sided sudden chest pain since 6days .
HOPI-
Patient was apparently asymptomatic 6yrs ago then he had an episode of loss of consciousness suddenly associated with sweating.He was taken to hospital in karimnagar and diagnosed with left hemiplegia and was under medication till now.
Now he came with the complaint of burning sensation in the left leg since 15 days which is persistent and with increased burning in the evening.
Associated with sudden right sided chest pain since 6days intermittently, dragging type , non radiating.
And generalized body weakness since 1 year.

PAST HISTORY- 
H/o left hemiplegia since 6years.
Not a known case of DM,HTN,Epilepsy,Asthma and coronary artery disease.
H/o Right eye catarct surgery.
DAILY ROUTINE:
He daily wakes up at 5am ,does his daily routine walk with stick and eats breakfast at 8 am.Then he watches tv and have lunch at 1 pm sleeps for about 2hrs and the go for walk with stick and have dinner at 8:00 PM and sleep at 10:00 PM.

PERSONAL HISTORY:
Diet: Mixed 
Appetite: decreased (since 2 months)
Bowel - hard stools once in 2 months,
Bladder-regular
Sleep:Adequate 
Addictions- Smoking since 40yrs ( one bidi packet per day)
Occassionally alcoholic since 30yrs
FAMILY HISTORY:
H/0 hemiplegia in grand father and father.

DRUG HISTORY:
No significant drug history.

GENERAL EXAMINATION:
Patient is conscious,coherent and co-operative.well oriented to time,place and person.
Moderatly build and moderatly nourished.

No pallor, icterus, cynosis,clubbing, lymphadenopathy ,edema
Vitals:
TEMPARATURE:afebrile
BP:140/90
PULSE RATE:80/min
RESPIRATORY RATE:16 cycles/min

CNS EXAMINATION:
Right handed person 

HIGHER MENTAL FUNCTION
Counsious ,oreinted to time place person
Speech normal
Behaviour normal
Memory intact 
Intelligence normal 

CRANIAL NERVE EXAMINATION
  -OLFACTORY-normal
 - optic : Decreased vision in left eye(Hand movements)
-oculomotor,trochlear,abducens -intact
-Facial nerve - intact
vestibulocochlear- intact
 - glossopharyngeal -intact
  - vagus-intact
  -accesory spinal ganglion nerve intact
  - hypoglossal intact

Sensory system:
-fine touch: intact
-pain: normal 
-temperature - normal
- vibration -normal
-stereognosis- normal
-two point discrimination-present

Motor system examination

Nutrition -

U/L. R. L
            Normal. Normal
L/L. Normal. Normal

TONE:
        U/L. R. L.
   
                         Normotania. Narmotonia 
         L/L 
                      Normotonia. Normotonia 
    
  

POWER. :- RIGHT. LEFT.
SHOULDER
flexion : 5/5 2/5
 Extension 5/5. 2/5

Abduction 5/5. 2/5

Adduction 5/5. 2/5

Internal rotation 5/5. 2/5

External rotation 5/5. 2/5

Elbow:5/5. 5/5

Flexion. 5/5. 2/5

Extension:5/5. 2/5

Wrist:5/5. 2/5

Flexion:5/5. 2/5

Extension:5/5. 2/5

Abduction : 5/5. 2/5

adduction:5/5. 2/5
5/5 
Hip

Flexion:5/5.    2/5 

Extension.  5/5.   2/5

Abduction:5/5.   2/5

Adduction 5/5.    2/5

Internal rotation:5/5.    2/5

External rotation.  5/5.    2/5

Knee 5/5.     2/5

Flexion 5/5.    2/5

Extension.   5/5.   2/5 

Ankle.  5/5.     2/5

Plantarflexion:.   5 /5.    2/5

Dorsiflexion.     5/5.  2/5

Toe.   5/5  2/5

Movements:5/5
REFLEXES: 

-Corneal present 

-Conjunctival present 

-Abdominal: present 

-Plantar: present 

*DEEP REFLEXES:

              Rt. Lt
Biceps : ++ +++
Triceps ++ ++
Knee : ++ ++
Ankle: + +

CEREBELLAR 
-NYSTAGMUS absent
-DYSADEADOCHOKINESIA absent 

FINGER NOSE tip- normal
Rhomberg sign -normal
Heel to knee intact

 Meningial sign :
 Kernigs sign negative 
Brudzinski sign negetive
 
Cvs- s1 s2 heard ,no murmur,apex beat at mid clavicular line at 5 th intercoastal space.

Respiratory system 
I: Chest bilaterally symmetrical, all quadrants
moves equally with respiration
P: Trachea central, chest expansion normal
P: Resonant
A: B/l equal air entry
B/I VBS
no added sound. 
Abdominal examination :-soft and non tender
No organomegaly.

PROVISIONAL DIAGNOSIS-
Left Hemiplegia with burning sensation in left leg.

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