Burning sensation in left upper limb and lower limb with left hemiplegia

Roll no-36

55 old male with left hemiplegia .

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 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 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. 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: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

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:little dorsiflexion

*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.