56 years old male presented to the Gm op

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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. 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 patients 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.

56 YEARS OLD MALE PRESENTED WITH 

Chief complaints:

 Weakness in both left upper limb and lower limb since 2 years 

 Pain in the Right hip and ankle joint since 4 days

History of presenting illness :

 patient was apparently asymptomatic 2years ago then he developed weakness in the left upper limb and lower limb - sudden in onset started after finishing his work and returning home at 6:00 pm . immediately went to local hospital and CT was done and started on medication.Took medication for 6months and then stopped taking medication weakness gradually increase to difficulty in walking 

N/H/O loss of sensation, N/H/O loss of consciousness, N/H/O up rolling of eye balls, involuntary movements of UL and LL drooling of saliva or deviation of angle of mouth ,uses of homeopathic medication for 1year and stopped.

Pain in the Right hip and ankle joint since 4days 

N/H/O trauma / fall 

Past history:

N/k/c/o HTN /DM/CAO/THYROID/SEIZURES DISORDER 

Personal history:

Diet - mixed 

Appetite -Normal 

Bowel and bladder - regular 

Sleep - adequate

Addiction - Nill 

Treatment history :

Not significant

Family history: Not significant 

General examination:

Patient was conscious,coherent, cooperative ,moderately built and Nourished 

Vitals : 

BP-110/70mmhg

PR -82bpm

RR -18cpm

Temp-96.8F

SPO2-95% at RA 

GRBS -124

No pedal edema ,lymphadenopathy ,pallor,icterus,clubbing 

Systemic examination:

CNS EXAMINATION: GCS -E4 V5 M6

Gait - circumduction gait 

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

Speech : Normal 

Behavior : is not aggitated and not irritable 

Memory : Normal

Intelligence :  Normal

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : visual acuity is normal

          

3rd,4th,6th : Normal 

5th : sensory intact

        

7th : Ability to blow cheeks

8th : No abnormality noted.

9th,10th : palatal movements present and equal.

11th,12th : normal.

MOTOR EXAMINATION: Right Left

                                    RT           LT 

POWER -     UL          5/5.        3/5

                      LL          5/5.      . 3/5

TONE. -         U L          N       Hyper

                        LL          N.      Hyper

REFLEXS - biceps.       1+.      3+

                  Triceps       1+.       3+ 

                  Supinator.     -          2+

                   Knee            1+.        3+

                  Ankle.           1+.         2+

                  Plantar           flexed

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch - normal

pain felt on  upper limb

Supraorbital pressure felt

Sternalrub pain felt 

DORSAL COLUMN SENSATION:

Fine touch able to perceive on right upper and lower limb

CEREBELLAR EXAMINATION:

  Finger nose test able to perform with both hand

  Nystagmus not seen

SIGNS OF MENINGEAL IRRITATION: absent

GAIT: circumduction gait 

Respiratory system:

Inspection: chest shape normal, 

No scars , no engorged veins 

Movement of chest both sides 

AUSCULTATION :

Bilateral air entry 

Normal vesicular breath sounds 

PALPATION:

Trachea central 

Cvs :

Inspection:

There are no chest wall abnormalities 

The position of the trachea is central. 

Apical impulse is not observed.

There are no other visible pulsations, dilated and engorged veins, surgical scars or sinuses. 

Palpation:

Apex beat was localised in the 5th intercostal space 2cm lateral to the mid clavicular line 

Position of trachea was central 

There we no parasternal heave , thrills, tender points. 

Auscultation: 

S1 and S2 were heard 

There were no added sounds / murmurs. 

Abdominal examination: 

Shape : scaphoid

Tenderness -no 

Free fluid -no 

Liver,spleen -not palpable 

Investigation: 

 Diagnosis :  known case of CVA with HEMIPLEGIA