LONG CASE
Dr Pallabi Dash
3rd Year Post Graduate
Name: Nukul Trivedi
Age : 26 years
Sex : male
Address: Cuttack
Occupation: Banker
Date of admission : 7/ 10/ 2022
CHIEF COMPLAINT
Inability to move left arm and leg for 7 days
Headache 1 week
Inability to move left side of face for 7 days
Blurring of vision in right eye 15 days
Head reeling 1 day before
Sudden onset weakness in left side of body
HISTORY OF PRESENT ILLNESS
The patient was apparently alright 6 days back when to start
Patient
with hewas feltapparently alrightat12the
his head reeling months back.that
morning, To isstart with she
everything
developed
around him sharp
wasshooting
moving .pain
Few in her back
minutes which
after this,radiated to both
he was unable
her thighs.his
to move Theleftintensity
arm andofleg.
pain remained
This episodeconstant
was sudden withinchange
onset of
position, coughing
and weakness wasormaximal
sneezing on. the
Theredaywas no nocturnal and has
of presentation
exacerbation of pain. over
improved minimally Following
the lastwhich shemostly
5 days visitedinmultiple
the leg yet
physicians
the patientand had been
refuses on pain
to move the killers
affectedonside.
and off
He since
has alsothen.
been
complaining of inability to move left side of his face which is
associated
Two monthswith
backdrooling of saliva
the patient from left
developed angleonset
gradual of mouth and of
weakness
deviation
right of face to
leg followed byright sideafter
left leg while15trying toevident
days as open mouth.
by inability to
Thereslippers.
wear hasn’t been any complains
She could manage toofwalk loss with
of consciousness or
a stick, subsequently
fall,weakness
the vomiting,progressed
convulsions, double
to such an vision,
extent language difficulties
that she could no longer
or swallowing
walk even with difficulties.
support from last 20 days.
Along with weakness of limbs she also felt numb below groin.
HISTORY OF PAST
ILLNESS
No similar episode in the past
He is not a known case of diabetes, hypertension,
heart disease, migraine, seizure disorder, sickle cell
anemia
No history fever, headache, cough or weight loss
No history of illicit drug abuse
No history of joint pain or rash.
FAMILY HISTORY
Nothing suggestive.
PERSONAL HISTORY
Socioeconomic Status- upper middle class
Educational qualifications: BSc
Occupation- banker
Both veg and non veg diet
Occasionally takes alcohol and cigarettes
TREATMENT HISTORY
Has previously
Currently been treated
admitted in MMW symptomatically for her thigh
5 and is being treated with
pain
1. Inj mannitol 20% w/v 1 bottle IV TDS
Tab Atorvastatin
Currently
2. admitted to 40
6thmg ODDepartment of Medicine
unit,
and
3. beingAspirin
Tab evaluated
75 mg OD
4. Tab Clopidogrel 75 mg OD
Summary of history
26 years non diabetic non hypertensive male banker from
Cuttack, presents with acute onset hemiplegia and facial
nerve palsy on left side without any history suggestive of
seizure disorder, Sickle cell anaemia, migraine, cardiac
disease, infections, connective tissue diseases. The patient
gives no history of illicit substance abuse but he occasionally
takes alcohol and cigarettes. Currently the patient is being
treated with Mannitol, anti platelets drugs and statins.
GENERAL EXAMINATION
Patient is conscious, cooperative
Body built : Thin built
Length = 1.67m
There is no pallor, icterus, cyanosis, clubbing, pedal edema
or enlarged lymph nodes.
JVP is not raised.
No thyroid enlargement
Condition of Skin, Hair and nail are normal
Pulse: 76/min, regular, normal in volume & character, no radio -
femoral delay, arterial wall just palpable, all peripheral pulses are
well felt
Blood Pressure: 112/60 mm of Hg in Right arm supine position.
Respiratory rate: 15 /min, regular, abdomino thoracic.
Temperature - 98.6° F oral
EXAMINATION OF NERVOUS
SYSTEM
HIGHER FUNCTIONS OF CNS
Patient is conscious, cooperative, well oriented to time,
place and person
Has normal speech and language
Intact memory, insight, judgement and abstract thought
Can do simple arithmetic calculations and can draw a clock
face.
EXAMINATION OF THE CRANIAL NERVES
1.Olfactory nerve :
Sense of smell in both the nostrils intact.
2.Optic:-
Visual acuity- Both eye normal
Colour Vision- Both eye normal
Field of vision- Both eye normal
Fundoscopy- Normal
3.Oculomotor, Trochlear, Abducens Nerve:
No Ptosis
Movement of eyeballs : normal in all direction
Pupils: size and shape normal and equal in both eyes.
Light reflex: direct and consensual light reflex present in
both eyes
Accommodation reflex present.
4. Trigeminal Nerve:
No weakness of muscle of
mastication
Sensation over face normal
Corneal reflex present in both the
eyes
Jaw jerk absent
5. Facial nerve
Absence of nasolabial fold on left side
Wrinkles on forehead present on both side
Weakness in muscles of facial expression on left lower half of
the face
Taste sensation in anterior 2/3rd of the tongue intact.
6. Vestibulocochlear Nerve :
Rinne’s test: AC>BC
Weber’s test: not lateralized.
7. Glossopharyngeal & Vagus Nerve:
Uvula central.
Palatal movement- bilaterally normal.
Gag reflex- present.
8. Accessory Nerve :
No weakness of Sternocleidomastoid and Trapezius muscle.
9. Hypoglossal Nerve :
Movements of tongue muscle normal, no deviation.
No atrophy, no fasciculation
MOTOR SYSTEM EXAMINATION
1.BULK: no wasting of muscles
RIGHT LEFT
ARM 32cm
32cm
FOREARM 23cm 23cm
THIGH 45cm 44cm
LEG 37cm 36.5cm
2.TONE
Tone Around the joints of right upper and lower limb: normal
Tone Around the flexors of elbow and extensors of knee is spastic
3. POWER:
JOINT MUSCLE GROUPS RIGHT LEFT
SHOULDER ABDUCTORS 5/5
0/5
ADDUCTORS
5/5 0/5
FLEXORS
5/5 0/5
EXTENSORS
5/5 0/5
ELBOW FLEXOR
5/5 0/5
EXTERSORS
5/5 0/5
WRIST EXTENSORS
5/5 0/5
FLEXORS
5/5 0/5
HAND GRIP NORMAL Absent
JOINT MUSCLE GROUPS RIGHT LEFT
HIP ABDUCTORS 5/5 0/5
ADDUCTORS 0/5
5/5
FLRXORS
5/5 0/5
EXTENSORS 5/5 0/5
KNEE FLEXOR 5/5 0/5
EXTERSORS
5/5 0/5
ANKLE DORSIFLEXORS 5/5 0/5
PLANTAR FLEXORS 0/5
5/5
4) REFLEXESDEEP TENDON REFLEXES
Right Left
Upper Limb Biceps Normal Exaggerated
Triceps Normal Exaggerated
Supinator Normal Exaggerated
Lower Limb Knee Normal Exaggerated
Ankle Normal Exaggerated
SUPERFICIAL REFLEXES :
Abdominal reflex :
Right side= present
Left side = absent
Plantar :
Right side = flexor
Left side = Extensor
SENSORY EXAMINATION
All primary modalities of sensations are present on both right
and left side side of the body
Cortical sensations are present on right side of body
Cortical sensation are absent on left side of body
CO-ORDINATION
Intact on right upper and lower limb
Could not be tested on left lower and upper limb
GAIT : could not be tested
INVOLUNTARY MOVEMENT : Absent
CEREBELLAR SIGNS:
Absent on right upper and lower limb
Could not be tested on left lower and upper limb
AUTONOMIC NERVOUS
AUTONOMIC NERVOUS SYSTEM SYSTEM
SKULL
Bowel AND SPINE:
and bladder normal
sensation and control-normal
No postural hypotension.
MENINGEAL SIGNS: Absent
PERIPHERAL NERVE : not thickened
EXAMINATION OF
CARDIOVASCULAR SYSTEM
INSPECTION :-
Precordium normal in shape
No dilated veins and visible scars seen
Apical impulse not visible
No other pulsation seen.
PALPATION:-
Apical impulse -present in left 5th ICS , on Mid clavicular
line, normal in character.
Pulmonary area : P2 not palpable.
No thrill.
PERCUSSION:-
2nd left intercostal space - resonant
Cardiac dullness starts from left 3rd ICS & does not
extend beyond the apex
AUSCULTATION :-
1) MITRAL AREA:
1st heart sound normal
No added sound.
No murmur
2) PULMONARY AREA :
Pulmonary Component of 2nd Heart Sound Normal
No Split
No added sound
3) AORTIC AREA :
Aortic component of 2nd heart sound normal
No added sound
No murmur
4) TRICUSPID AREA:
1st heart sound heard normal
No murmur
5) carotid bruit: not audible
EXAMINATION OF RESPIRATORY SYSTEM
UPPER RESPIRATORY TRACT-normal
EXAMINATION OF CHEST:
INSPECTION :-
Trachea appears to be central in position
Apical impulse not visible
Chest bilaterally symmetrical
Bilateral Chest movement equal
No paradoxical chest movement.
PALPATION:-
Trachea is confirmed to be central
Apical impulse is present in left 5th ICS on MCL
Chest expansion is 5 cm
Vocal fremitus is normal
There is no Intercostal tenderness
PERCUSSION :-
Direct percussion over clavicle is normal bilaterally
Percussion over left and right hemithorax is normally
resonant
AUSCULTATION :-
Normal bilateral vesicular breath sound heard.
Normal vocal resonance bilateral.
No adventitious sound.
EXAMINATION OF GI SYSTEM
Mouth and oral cavity normal.
INSPECTION:-
Shape of abdomen is normal
Umbilicus central & inverted
Midline scar present below umbilicus
PALPATION:-
Liver not enlarged, Spleen not palpable
PERCUSSION:-
Abdomen is tympanitic.
no shifting dullness
AUSCULTATION:-
Bowel sound 3/min
SUMMARY
26 years non diabetic non hypertensive male banker from
Cuttack, presents with acute onset hemiplegia and facial
Anerve palsyold
40 year on female
left side.presented
His general withexamination is normalback
chronic radicular
withwith
pain stablegradual
vitals. Examination of higherprogressive
onset, asymmetrical functions ofweakness
CNS
and numbness
and all cranial nerve
of bothexamination
lower limb arewithout
normal expect
any bowelfor and
UMN paralysis
bladder of left facial nerve. Motor examination shows
involvement.
a power of 0/5 on left upper and lower limb with Hypertonia
on flexors of left elbow and extensors of left knee. All DTR
On
are examination
exaggerated on there
left is spastic
side. Among asymmetric
superficial paraparesis
reflexes, of
both lower limbs,
abdominal reflex iswhich
absent is on
more
left over the right
side with sidebabinski
positive than left
and
sign is
on associated withSensory
the same side. an extensor plantar
examination showsresponse and
absences
exaggerated knee andonankle
of cortical sensation jerks.
left side. RestAnkle
of theclonus
CNS andisotherpresent
bilaterally. There is loss
system examination areof all primary
within normalmodalities
limits. of sensations
below L1 dermatome.
Function affected
Structure
involved
Motor function around all joints of left upper and Cortico spinal tract
lower limb
Exaggerated DTR on left side
Extensor plantar on left side
Motor function in left lower half of face Cortico nuclear tract of Facial
Nerve
Cortical sensation on left side Parietal cortex
PROVISIONAL DIAGNOSIS
Left sided hemiplegia with UMN facial palsy on left side due
cerebrovascular accident- infarct in right fronto parietal cortex
due to artery to artery atheroembolic occlusion in superior
division of M2 segment of MCA.
DIFFERENTIAL DIAGNOSIS
Todd’s paresis
Hemiplegic migraine
Cerebral venous infarct
Tumour bleed
Demyelination
INVESTIGATIONS
Hemoglobin: 12.4 gm% Lipid profile
TLC: 5550/ cmm Chol 102 mg/dL
N76 L 22 TG. 52 mg/dL
TPC 2.71lakh / cmm HDL. 32 mg/dL
LDL. 60 mg/dL
ESR: 40 mm in 1 st hr VLDL. 10 mg/dL
Viral markers : Negetive
RBS: 78 mg/dl ECG : WNL
Serum Urea: 30 mg/dL 2D ECHO: normal LV systolic
function
Serum Creatinine: 0.5 mg/dL
Serum Sodium: 141 meq/l
Serum Potassium: 4.1 meq/l
Serum Calcium:(ionized) 0.9mmol/l
Sr Bilirubin total- 0.5mg/dl
Sr Bilirubin direct0.2mg/dl
AST-33 IU/L
ALT-38 IU/L
ALP-196 U/L
INVESTIGATIONS
Hemoglobin: 12.4 gm%
TLC: 5550/ cmm
N76 L 22
TPC 2.71lakh / cmm
ESR: 20 mm in 1 st hr
Serum Urea: 30 mg/dL
Serum Creatinine: 0.5 mg/dL
Serum Sodium: 141 meq/l
Serum Potassium: 4.1 meq/l
Serum Calcium:(ionized) 1.2mmol/l
HBsAg: Negative
HCV : Negative
HIV: Negative
FINAL DIAGNOSIS
Left sided hemiplegia with UMN facial palsy
due cerebrovascular on left infarct
accident- side duein
cerebrovascular accident-
genu and posterior limb ofinfarct in right capsule
right internal fronto tempo
due toparietal
cortex due to artery
atheroembolic to artery
occlusion atheroembolic
in M2 occlusion
branches of MCA in superior
artery.
and inferior division of M2 segment of MCA.
THANK YOU
