1601006088 LONG CASE

 

HT no: 1601006088 - LONG CASE

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CASE: 

            A 50 year old female who is farmer by occupation, resident of suryapet came with chief complaints of weakness in left upper and lower limbs since 4 days.

HISTORY OF PRESENTING ILLNESS: 

          Patient was apparently asymptomatic 4 days ago then she had dizziness which was sudden in onset then she developed weakness in her left upper and lower limbs followed by fall. Weakness in the limbs was sudden in onset, rapidly progressed to a state where she was unable to move her left side of the body. It was associated with drooping of angle of mouth on left side, with speech difficulty and there was deviation along with  drooling of saliva from the angle of mouth when she attempted to speak

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

           There was no history of 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 which is under control by medication 

            No history of Tuberculosis, asthma, epilepsy, thyroid disease, cardiovascular disease.

 

FAMILY HISTORY: No relevant family history

MENSTURAL AND OBSTETRIC HISTORY: 

           She had underwent hysterectomy 4 years back for fibroid uterus.

           

PERSONAL HISTORY: 

           Diet - Mixed

           Appetite - Regular 

           Sleep - Adequate

           Bowel and bladder movements - regular

           No addictions 

ALLERGIC HISTORY: 

           No known allergic history 

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 : 75 bpm with regular rhythm and character 

         Respiratory rate : 15 cycles per minute 

         Blood pressure : 110/80 mm of Hg 

         Temperature : Afebrile 

SYSTEMIC EXAMINATION : 

      

Central nervous system :

   

Higher mental function: 

       Patient is consciousness, oriented to time place and person, emotionally stable, no loss of memory without behavioral abnormalities, speech is normal 

Cranial nerves:

                                                   RIGHT               LEFT

Olfactory nerve                       Intact              Intact

Optic nerve                               Intact              Intact

Occulomotor,

Abducense,                               Intact              Intact

Trochlear nerve

Trigeminal nerve                    Intact              Intact

Facial nerve 

   i) motor 

          Nasolabial fold              Present         Absent 

          Frowning                        Present         Present

          Closure of eyes              Present         Present

          Whistling                        Present         Absent 

   ii) sensory 

           Anterior 2/3rd of          Present        Present

            tongue

   iii) reflexes      

             Corneal                         Present        Present 

              Conjunctival               Present        Present 

Vestibulocochlear nerve       Intact            Intact

Glossopharyngeal, vagus      Intact            Intact 

Spinal accessory                      Intact            Intact

Hypoglossal nerve                  Intact            Intact

Motor system:

                                                RIGHT             LEFT

Bulk                                  No wasting     No wasting

Tone

      Upper limb                    Normal          Hypotonia

      Lower limb                    Normal          Hypotonia

Power

       Upper limb                     5/5                 0/5

       Lower limb                     5/5                 4/5

Superficial reflexes 

      Corneal                         Present           Present 

       Conjunctival              Present           Present 

       Plantar                        Flexor              Extensor

Deep reflexes 

      Biceps                               +2                   +2 

      Triceps                             +2                   +2 

       Knee                                 +2                   +2

       Ankle                         not elicited      not elicited

 

Sensory system :

     Superficial - Temperature, fine touch, pain are present 

      Deep - Positiom, Vibration, two point discrimination, Stereognosis, Graphaesthesia present 

Cerebellar function - Normal 

Coordination - Finger nose test, heel knee test present

Gait - Normal

           Rombergs - negative 

Signs of Meningeal irritation - Absent 

OTHER SYSTEMS 

     CVS - S1, S2 heard 

     Respiratory system - Bilateral air entry present, vesicular breath sounds heard

     Per abdomen - Bowel sounds heard

INVESTIGATIONS

     CT Scan

     ECG - Normal 

PROVISIONAL DIAGNOSIS :  Left UMN Facial Palsy with Left sided Hemiparesis