Case 16 - A case of right hemiplegia in a 50 year old man.

Case 16 - A case of right hemiplegia in a 50 year old man.

Hi, I am R. Ramya Keerthana, 5th semester medical student. 

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 patients 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 comment box is welcome. 

I've 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 a diagnosis and treatment plan.  

CONSENT AND DE-IDENTIFICATION : 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.

Case Scenario

General medicine ward

DOA: 16-06-23

A 50 year old man resident of Nagarjun Sagar came to OPD with chief complaints of: 

- paralysis of right upper limb and lower limb since 6 months

- hoarseness of voice since 6 months 

History of Presenting Illness

- patient was apparently asymptomatic 7 years ago when he had a fracture of left femur for which rod was placed surgically.

- 6 months ago he fell spontaneously and developed right sided hemiplegia for which he has been undergoing on and off physiotherapy sessions.

- he also developed dysphonia 6 months ago.

- h/o jaw pain and inability to open mouth fully.

- h/o right sided headache and fever spells.

- h/o pain in right hand which is sudden in onset, intermittent, dragging type relieved on massage.

- no h/o SOB, blurring of vision, vomiting, diarrhea, constipation.

Daily Routine 

- before 6 months, he used to wake up at 7 am have rice for breakfast and go to farm. He would have lunch (rice) at the farm and return home around 6 pm have dinner(rice) and go to sleep at 9 pm.

- since 6 months, he wakes up at random times between 5 am to 9 am, has meals when given by attender and lies in bed most of the time.

Past History

- seropositive

- k/c/o HTN since 1 year on medication

- n/k/c/o TB, DM, CAD, epilepsy, asthma, thyroid disorder.

- no h/o of blood transfusions.

Surgical History 

- appendectomy 40 years ago

- left femur fracture surgery 7 years ago.

Personal History

- married

- Used to work as a farmer but stopped working since 6 months 

- mixed diet

- normal appetite

- adequate sleep

- bowel and bladder incontinence 

- no known allergies

- chronic alcoholic and smoker

Family History

- h/o throat cancer (mother)

- no HTN

- no DM

- no heart disease

- no TB

- no stroke

- no asthma

- no other hereditary diseases

Drug History

General Examination

I have examined the patient after taken prior consent and informing the patient in the presence of a female attendant. The examination was done in both supine and sitting position in a well lit room. 

- patient was conscious, incoherent  and non-cooperative

- not oriented to time and space

- wasting of right upper limb present 

- no pallor

- no icterus

- no cyanosis 

- no clubbing of fingers

- no lymphadenopathy 

- bilateral pitting pedal edema present

- no malnutrition 

- no dehydration 

Vitals

- Temperature: afebrile 

- Pulse rate: 80 bpm, regular rhythm, normal volume

- Respiratory rate: 17 cpm

- BP: 130/90 mm Hg

- SPO2: % at RA

- GRBS: mg/dl

Fluid Intake and Urine Output

Total Input: ml

Total Output: ml

Fever Chart

Systemic Examination 

Cardiovascular System

- no thrills

- cardiac sounds S1 and S2 heard

- no cardiac murmurs

Respiratory System

- no dyspnea

- no wheeze

- trachea position: central

- breath sounds: vesicular

- no adventitious sounds heard

Abdomen

- shape: scaphoid 

- no scars, striae, engorged veins

- no tenderness

- bowel sounds heard

- no bruits, rubs

- no shifting of dullness

- no fluid thrill

- no palpable mass

- hernia orifices: normal 

- liver: not palpable 

- spleen : not palpable

Central Nervous System

- bilateral lower limb reflexes absent

- right upper limb hyperreflexia

- left upper limb reflexes normal 

Investigations

Provisional Diagnosis

Treatment