41 years old, chinese male from Muar Johor, whose currently unemployed came to the hospital 2weeks ago ( date of first examination 18 july) with the complaints of weakness of the left half of the whole body . ( it is quite difficult for me to communicate with him, so i got a few informations from my chinese friend who could talk with him ). he is a known IVDU and had multiple sexual partners before.
   the patient felt down in the house one day over the left half of his body and never loss his consciousness. he claimed that, he came to the hospital all by himself, but as far as my friend told me, his mother took him to the hospital. he`s single and stays only with his mother.  the patient is bed ridden from the day he was admitted till today. he could not get up to go to the bathroom , and that he has to be put in urinary catheter , and get them changed every 3 days. he told that he has several previous admissions in the hospital before.
 
on examination, the patient is alert however confuse and didnt talk much. he smokes even in the ward.he`s of moderately  built and undernourished.there`s multiple tatoos over his body. there are multiple excoriated skin lesions and depigmented old ulcers over his legs. today(27 july) the left ankle is bandaged.(i dont know why). he has multiple red skin macules over his chest and his arms.the patients currently pale, with no icterus, no clubbing, no cyanosis, and no pedal edema.oral hygiene - oral thrush, the teeth is stained with nicotine.
patient tolerating well with oral food.
      the pulse taken everytime for follow up are around (75-95 beats per min), regular rhythm, normal volume, no special character, no blood vessels thickening. and all peripheral pulses felt. the blood pressure are normals , patient was febrile for 3 days and currently normal.respiratory rate are normals, there`s nicotine stained in the fingers.there`s also no lymphadenopathy.
 
RS - bilateral creps (coarse)
CVS- S1 and S2 heard normal, no murmur
abdomen - soft, non tender, no organomegaly
 
the CNS examnations..i didnt do all sir,
the patient is not orientated to time, and has good memory
optic nerve- the visual acuity is 6/6, the visual field is good,
extra ocular movements is full range
there`s no facial assymetrical
there`s movements of palate and uvula
there`s symmetrical movements hypoglossal, but i couldnt elicit palatal,guttaral, or labial movements approriately
the patient could turn his head and shrugg his shoulder
there`s hypertonia of the left limb as well as lower limbs
the power of left UL is 5/5. right UL is 3/5
power of left LL is 1/5 . right LL is 3/5
the sensory present over the both UL . but it`s decresed in the left LL
upward plantar response
brisk reflexes on all 4 limbs
 
investigations
ct scan to rule out cerebral abscess/space occupying lesion
 
radiology : loss of disc space between L3 and L4
lumbarisation of S1 vertebra body
ankylosis of L3 L4
 
urine FEME - protein 4+
                     blood 3+
 
ESR - 112
sputum for AFB - negative
mantoux test - negative
 
blood investigations also reveals - salmonella species
 
LFT -
albumin , decresed 25g/dl
glubulin , increased
 
BUSE- uric acid , decreased to 129
sodium decreased
 
serum toxoplasmosis - comes positive
 
to check for his viral load - CD4 and CD8 level done(infective)
 
since 15th july- the patient has been monitored for his GCS, inform the doctor if dropping
 
on 19th july - CT scan of brain done again and IV contrast done
 
chest x ray - equally bilateral on the lungs...haziness
 
ECG- no changes
 
treatment -
syrup lactulose 15ml
syrup nystatin 50000 QID
ravin edema
 
20th july
CT scan - cerebral abscess & cerebral edema
increased tone on the right side too
 
patient still smokes in the ward
 
patient is to be referred to surgical for the venous cut down
 
also spine X ray - to rule out TB spine
 
GCS - E4 , V5, M6
pupils -3/3 equal
 
treatment added - heamtinics & cemidine - 1/1
 
plan : IV unasyn1.5grams TDS
         T. EES 80 mgs
          IV drip 4 paine , 2 paines of NS and 2 of DS

Sorry for the late response.

The anatomical diagnosis in this patient should be easier as a hemiparesis suggests extensive involvement and is more likely to be localized to internal capsule (although rarely it may be even a assymetric peripheral polyneuropathy which can be ruled out by simple rules of ruling out UMN vs LMN lesions).

Most students jump to the etiologic diagnosis of stroke when they see a hemiparesis but this case was to illustrate that all hemiparetics are not stroke. They can be be SOLs like this (toxoplasma) or even neoplasms etc. Rakesh