55yr old male came with burning sensation of left leg and left hand and right sided sudden chest pain.


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.


N.Gautham kanth 
Roll no. 103

CASE REPORT
A 55yr old male came with the chief complaints of burning sensation of left leg and left hand since 15 days and right sided sudden chest pain since 6days .

HOPI-
Patient was apparently asymptomatic 15 days back then had burning sensation in the left upper limb and lower limb which is persistent and with increased burning sensation in the evening.
Then he had trauma to the chest 6 days ago for which he had right sided chest pain which is intermittent, dragging type , non radiating aggrevated on inspiration.
----Since 1 year he has generalized body weakness.
----6yrs ago he had an episode of loss of consciousness associated with sweating for which  he was taken to hospital in karimnagar and diagnosed with left hemiparesis and was under medication till now.

PAST HISTORY:
H/o head injury 20yrs ago and sutured for it.

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 for 1 hour 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 for 1 hour 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 since 10 days
Bladder-regular
Sleep:Adequate and sound.
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, co-operative and 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 mmhg
PULSE RATE: 80 beats/min
RESPIRATORY RATE:16 cycles/min
CNS EXAMINATION:

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 palsy is seen 
-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.   Decrease 
L/L.     Normal.     Decrease 

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

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:

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

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                     

Flexion                 5/5           2/5

Extension.           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: dorsiflexion of toes in left leg.

*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 
Chest bilaterally symmetrical, all quadrants
moves equally with respiration
 Trachea central, chest expansion normal
NVBS 
Abdominal examination :-soft and non tender
No organomegaly

INVESTIGATION










PROVISIONAL DIAGNOSIS-
Left hemiparesis with burning sensation in left upper limb and lower limb.

Acute ischemic stroke ??

Treatment

1. INJ OPTINEURON IV OD
(1 ampule in 100 mL NS)

2. TAB PREGABLIN 75mg po/HS

3. TAB ECOSPIRIN AV (75/20) po/Hs

4. TAB PAN 40mg po OD BBF

5. Physiotherapy of Left UL LL

BP PR RR charting 6th hrly

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