1601006035 LONG CASE

 

Hall ticket:1601006035 Long case

 


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case:

A 50 year old female farmer by occupation resident of suryapet came to opd with chief complaints of weakness of left upper and left lower limbs since 3 days

 

History of present illness:

patient was apparently asymptomatic 3 days ago then developed dizziness and then she developed weakness in her left upper and lower limbs following a fall

weakness was sudden in onset and it was progressing in such a way that she was unable to move the left side of the body 

there was also drooping of angle of mouth on the left side associated with difficulty in speech and drooling of saliva is also present

there was no loss of memory no behaviour abnormality no loss of consciousness

there was no h/o fever,nausea,vomiting,headache,dyspnea


past history:

no similar complaints in past

she is a known case of diabetes and hypertension from 4 years

no h/o tuberculosis,asthma,epilepsy,thyroid disease


Family history:not significant


menstrual history:

hysterectomy 4 years back for fibroid uterus has done


Allergic history:not significant

Personal history:

diet:mixed

Appetite:normal

Sleep-adequate

Bowel and bladder movements are 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 of hg

Temperature-afebrile

 

Systemic examination:

Examination of higher mental functions:

Patient is conscious and oriented to time and place there is no loss of memory

Examination of cranial nerves:

1.olfactory nerve:smell is present

2.optic nerve:visual acuity 6/6 present and colour vision normal

3.oculomotor nerve:eyeball movements normal and accomodation reflex present

4.trochlear nerve:intact

5.trigeminal nerve:corneal and conjunctival reflex are present

7.facial:

There is deviation of the mouth to the right side and absence of nasiolabial fold on the left side

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



8.vestibulocochlear nerve:intact on both eyes

9.glossopharyngeal nerve:intact

10.vagus nerve:intact and taste sensation is present on posterior 1/3 of tongue

11.spinal accessory nerve:shrugging of shoulders presents

12.hypoglossal nerve:there is no deviation of tongue

Examination of motor system:

Bulk-there is no wasting of muscles

Tone:                   Right        Left

Upper limbs:           N             N

Lower limbs:            N             N


Power:

Upper limbs              5/5        0/5

Lower limbs               5/5            4/5


Reflexes:

Superficial reflexes:     Right         Left

-Corneal reflexes:          Present        Present

-conjunctival reflexes:    Present         Present

-plantal reflexes:             Normal          Extensor


Deep reflexes:              Right           Left

-Biceps                            +2               +3

-triceps                              +2              +2

-knee                                  +2             +2

-ankle                                   Absent.       Absent


Examination of sensory system:

-superficial:fine touch,temperature,pain present

-deep: positions two point discrimination is present 


Cerebellar function: normal

Coordination and gait:

Finger nose test,heel knee test present

Gait: It is of dragging type


Other systems:

Cvs: s1 s2 heard

Respiratory system:bilateral air entry present

Git: per abdomen normal


Investigations:

Ct was done which was normal 





Provisional diagnosis:

Left UMN facial palsy with left sided hemiparesis







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