55 yr old male with Hemiplegia.

Get link
Facebook
X
Pinterest
Email
Other Apps

January 02, 2023

January 01,2023

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 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.

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 HISTORY:

A 55yr old male came with the chief complaints of burning sensation in left leg and left hand 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 upper limb and lower limb since 15 days which is persistent and with increased burning sensation 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 head injury 7yrs ago and sutured for it.

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 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- slightly slurred.

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. Increased

L/L

Normotonia. Increased

POWER. :- Rt Lt

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 2/5

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

Hip Rt Lt

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 upper limb and lower limb.

Get link
Facebook
X
Pinterest
Email
Other Apps

Comments

A 60yr(M) chronic Alcoholic with Abdominal Distension

July 09, 2023

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT Complaints- A 60yr old male came with complaints of -abdominal distension -decreased urine output since 4 months -Swelling of B/L lower limbs HOPI - Patient was aparently asymptomatic 4 months back.He then developed abdominal distension which was insiduous in onset , gradually progressive associated with pain abdomen- squeezing type in umbilical region , aggravted on taking food with no releiving factors . H//O decreased urine output since 4 months H/O EDEMA in B...

55 yr old with sluring of speech

March 16, 2023

1801006059- Long Case This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solveb those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome. CASE- A 55 year old male with chief complaints of - deviation of mouth to left side since 2 days and - slurring of speech since 2 days History of presenting illness: Patient was apparently asymptomatic 2 days ago. He then developed slurring of speech which was sudden in onset . He also developed B/L blurring of vision which was sudden in onset and which lasted for an hour . On the same day his wife noticed deviation of mouth to left side and was t...

64 yr old male with vomitings and Right flank pain.

August 02, 2022

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 02/08/2022 Aruna.J Roll no.61 A 64 year old male resident of Chotuppal came with chief complaints of 1. Vomiting since 15 days 2. Burning micturition since 15 days 3. Right flank pain since 15 days HOPI: Patient was apparently asymptomatic 15 yrs back.Then he developed pain in the right loin and was diagnosed with renal calculi(bladder) and was operated and then 3 yrs later again he developed bilateral loin pain and was diagnosed with bilateral renal calculi (ureters) and was operated with a gap of one month. Then 3 yrs later he developed a midline swelling approx 3 cm below umbilicus and diagnosed with abdominal hernia and a mesh was placed. Then 1 yr later he developed abdominal pain and endoscopy was done and diagnosed with ulcer and was managed conservatively During this he was diagnosed with diabetes and ...

Search This Blog

ARUNA.J ROLLNO.61