A 55 yr old male with Hemiparesis assosiated with burning sensation of left upper and lower limb secondary to stroke

A 55yr old male resident of nalgonda presented to OPD 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 suffered from a sudden episode of loss of consciousness associated with sweating. He was taken to a nearby hospital and was diagnosed with left hemiplegia and is using medicines till today.

The burning sensation is persistent and is increasing in intensity during evenings.

There is history of fall from bed due to which he developed a sudden right sided chest pain since 6days and is intermittent, dragging type , non radiating, which increases on inhaling air

There is history of generalized body weakness since 1 year.

PAST HISTORY :- 

H/o head injury 20 yrs ago and got sutured for it.

H/o left hemiplegia since 6years.

Not a known case of DM,HTN,Epilepsy,TB 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 goes for walk with stick and has dinner at 8:00 PM and sleep at 10:00 PM.

PERSONAL HISTORY :-

Diet: Mixed 

Appetite: decreased (since 2 months)

Bowel - hard stools since last 10 days,

Bladder-regular

Sleep: inadequate 

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.

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 : normal

-oculomotor,trochlear,abducens -intact

-Facial nerve - loss of nasolabial fold and deviation of mouth on the right side

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.

ELBOW:5/5. 3/5

Flexion. 5/5. 3/5

Extension:5/5. 3/5

Wrist:5/5. 3/5

Flexion:5/5. 3/5

Extension:5/5. 3/5

Abduction : 5/5. 3/5

adduction:5/5. 3/5

KNEE :- 5/5. 3/5

Flexion 5/5. 3/5

Extension. 5/5. 3/5 

ANKLE :- 5/5. 3/5

Plantarflexion:. 5 /5. 3/5

Dorsiflexion. 5/5. 3/5

Toe. 5/5 3/5

Movements:5/5

REFLEXES: 

-Corneal present 

-Conjunctival present 

-Abdominal: present 

-Plantar:little dorsiflexion

*DEEP REFLEXES:

              Rt.     Lt

Biceps : +2   +3

Triceps +2     +1

Knee : +3    +3

Ankle: +2       +2

CEREBELLAR 

-NYSTAGMUS absent

-DYSADEADOCHOKINESIA absent 

FINGER NOSE tip- normal

Rhomberg sign -normal

Heel to knee intact

Babinski's sign - positive 

 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 is central, chest expansion normal

B/l equal air entry

B/L VBS

no added sound. 

Abdominal examination :-soft and non tender

No organomegaly.

PROVISIONAL DIAGNOSIS :-

Left Hemiparesis with burning sensation in left upper limb and lower limb.

INVESTIGATIONS :-

TREATMENT :-

- Inj. Optineuron

- Tab Pregabalin

- Tab Ecosporin

- Tab PAN

- Physiotherapy of left upper limb and lower limb

- Bp, pulse rate and respiratory rate charting 6 hrly.