55 yr old male with Hemiplegia.
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January 01,2023
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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 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.
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