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 

 


 








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