Final Exam Long Case

Hall Ticket No: 1601006042

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CASE

A 50yr old female,farmer by occupation, resident of suryapet came with chief complaints of weakness in left upper and lower limbs since 3 days.

History of present illness:

Patient was apparently asymptomatic 3 days back ,then she developed dizziness which was sudden in onset .Then she developed weakness in her left upper and lower limbs followed by fall.Weakness was sudden in onset and progressed rapidly to a state where she was unable to move her left lower limb and left upper limb.It was associated with drooping of angle of mouth on left side ,with speech difficulty and there was deviation of mouth to the right side, associated with drooling of saliva.

It was not associated with loss of consciousness,loss of memory, seizure activity, behaviour abnormalities, bowel or bladder incontinence or visual disturbances.

No H/o fever,nausea,vomiting,headache,chest pain and dyspnea.

Past history:

No similar complaints in the past .

She is a known case of Diabetes and hypertension since 4 years .

No H/o of Tuberculosis , asthma , epilepsy , thyroid disease, cardiovascular diseases.

Family history: no relevant family history

Menstrual history:

She had undergone Hysterectomy 4 years back for fibroid uterus.

Allergic history : No known allergic history.

Personal history :

Diet - mixed   

Appetite - Normal

Sleep - Adequate

Bowel / bladder movements - Regular

No addictions 

General Examination :

Consent obtained

Patient was conscious , coherent and cooperative,well built and well nourished.

No pallor , icterus , cyanosis , clubbing, koilonychia, general lymphadenopathy and edema.

VITALS :

Pulse - 75bpm with regular rhythm and character

Respiratory rate - 15cpm

Blood pressure - 110/80mm Hg

Temperature - Afebrile

Systemic Examination :

Central nervous system examination-

1. Higher mental functions -

Patient is conscious ,oriented to time,place and person.

Emotionally stable

No loss of memory

No behaviour abnormalities

Speech normal

2. Cranial nerve Examination -

Olfactory nerve - smell present on both sides

Optic nerve - visual acuity 6/6, visual field ,color vision normal on both sides

Cranial nerves 3,4,6 - intact on both sides

Trigeminal nerve - intact on both sides

Facial nerve 

Nerve affected on the left side

- deviation of mouth to the right side

- frowning present

- absent nasolabial fold on left side

- blowing and whistling absent

Taste sensation on anterior 2/ 3 rd of tongue is present.

Corneal reflex - present on both eyes

Vestibulocochlear nerve - intact on both eyes

Glossopharyngeal and  vagus nerve - intact

Spinal accessory nerve - shrugging of shoulder present 

Hypoglossal nerve - tongue movements normal.

3.Motor system

A)Bulk - no wasting

B)Tone -  Right      left 

UL   -     N              Hypotonia

LL   -     N              Hypotonia

C)Power: Right      left 

UL.       5/5.         0/5

LL.        5/5.         0/5

D) Reflexes: 

Superficial.   Right.       Left

Corneal          present        present

Conjunctival   Present      present  

Plantar.        Flexor         Extensor

Deep.          Right.           Left

Biceps        +2.                 +2

Triceps.      +2.                +2

Knee.           +2.               +2

Ankle.        Absent.         Absent

4) Sensory system:

Superficial - fine touch , temperature ,pain present.

Deep - position , vibration ,two point discrimination,stereognosis,graphesthesis present.

5)Cerebellar functions:

Normal

6)Coordination and gait :

Finger nose test ,finger finger test ,heel knee test present.

Gait - dragging type

7)Signs of meningeal irritation absent

Other systems :

CVS - S1 ,S 2 heard

Respiratory - Bilateral air entry present 

GIT - normal

Differential diagnosis

-Cerebral embolism

-Subarachnoid hemorrhage

-Cerebral hemorrhage 

-ICSOL

Investigations :-

CT - normal

ECG:

Provisional diagnosis :-

Left UMN facial palsy with left sided hemiparesis.

Treatment received till now

-atorvastatin

-ecospirin

-clopidogrel