Farrukh Hayat Khan, Shakeel Ahmed Mirza.
Importance of review in diagnosis.
Pak Armed Forces Med J Jan ;57(4):339-40.

A 32-year-old married soldier was admitted in medical ward with two episodes of unconsciousness and falling down during last 10 days. Both the time he regained alertness within 15 minutes with no change in complexion and there was no history of any frothing, tongue bite, injury, incontinence, tonic clonic movement or postictal confusion. He also complained of occasional weakness and numbness left side of body and pain in the occipital region. There were multiple psychosocial stressors including posting to unwanted station, financial containments and being issueless even after 5 years of marriage; however there was no marital or sexual problem. On physical examination no abnormality could be detected except inconsistent finding of reduced power (4/5) on left side. All routine and specialized investigations were normal. He was thus referred to psychiatrist with provisional diagnosis of Dissociative Disorder of Sensation and Movement and transferred to psychiatry ward. He was put on Fluoxetine 20 mg / day. While reviewing him after an interval of a month it was revealed that twice he was seen without slippers in left foot as they slipped while walking without his awareness. On re-examination he was found to drag his left foot while walking. Muscle power in left upper and lower limb was 2/5 and 3/5 respectively and the tendon reflexes were exaggerated. Light touch, superficial pain and vibration sensations were lost on left side of face, trunk and upper and lower limb and planter reflex could not be elicited. There was paresis of left facial nerve. He was thus again shifted to medical ward. CT Scan Brain was repeated which showed decreased density of brain matter in the region of right parietal lobe and right basal ganglia, margins of hypo dense area were ill defined and showed poor and heterogeneous enhancement. These findings were consistent with diagnosis of cerebral infarction and the final diagnosis of right parietal lobe infarction was made.

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