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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