STROKE

NAME : [Link]
FINAL YEAR , MBBS
BGS GIMS
PATIENT PARTICULARS
• NAME: [Link]
• Age: 61 years
• Gender: female
• Address: Ramnagar
• Occupation: housewife
• Education: 8 th standard
• Socioeconomic status: Lower Middle class according BG Prasad
• Informant: sister in law (reliable)
• DOE: 12/06/21
• Handedness: Right handed
CHIEF COMPLAINTS
• WEAKNESS IN RIGHT UPPER AND LOWER LIMB SINCE 5
DAYS
• DEVIATION OF ANGLE OF MOUTH TO LEFT SIDE SINCE
5 DAYS
• SLURRING OF SPEECH SINCE 5 DAYS
HISTORY OF PRESENTING
ILLNESS
• Patient is a known hypertensive and is on medication for the same
• Patient was apparently normal and performing her routine activities
until 5 days back
• The patient went to sleep at 11 p.m and woke up at 5 a.m the next
day and the patient experienced weakness in right upper limb and
lower limb
• She initially felt weak in the right upper limb and eventually felt
weakness in the right lower limb
• She was unable to hold a glass of water and comb her hair
• She had difficulty in squatting , gripping her slippers
• Weakness is equal in both upper and lower limb
[Link] presented with deviation of angle of mouth to
left side while speaking and showing teeth since 5 days
which was sudden in onset associated with drooling of
saliva
She had difficulty in chewing food
• Patient had no difficulty in closing her eyes
• [Link] had slurring of speech since 5 days
• Sudden in onset
• She was able to understand the command ,use
appropriate words while talking
• She could not repeat the sentences and the fluency is
reduced
• Patient was taken to hospital the next day
At or before the onset of
symptoms
• No h/o headache , nausea, vomiting
• No h/o head or spine trauma
• No h/o loss of consciousness
• No h/o transient loss of vision
• No h/0 altered sensorium, behavioural abnormalities
• No h/o seizures
• No h/0 fever
• No h/o involuntary movements
• No h/o urinary and fecal incontinence
• No h/o loss of sensation ( was able to appreciate her clothes )
No h/o loss of balance , swaying while walking
• No h/o double vision
• No h/o tinnitus ,vertigo
• No h/o difficulty in swallowing , nasal regurgitation , hoarseness of
voice
• No difficulty in neck/shoulder movements
• No h/0 persistent hiccoughs
• No h/o pain / burning sensation
• No h/o chest pain, palpitations , breathlessness
• No h/o pain in calf muscles
Past History
• No history of similar complaints in the past
• A known hypertensive since 8 years and is on treatment
for the same ( AMLODIPINE )
• No h/o Transient ischaemic attacks
• Not a known case of diabetes mellitus/ bronchial
asthma/ COPD/ tuberculosis/ ischemic heart disease/
rheumatic heart disease / bleeding or clotting disorders/
epilepsy / peripheral vascular disease
• No h/o prior surgeries in the past
• No h/o allergies
Drug history
• On medications for hypertension since 8 years
• No history of use of anticoagulants , oral
contraceptive pills
Family history
• No h/o stroke in the family
• No h/o stroke in young in the family
Personal History:

• Consumes mixed diet

• Post menopausal women
• Has normal appetite
• Adequate sleep
• Regular bowel And bladder habits
• No h/o smoking and consumption of alcohol
• No h/o drug abuse
Summary
• A hypertensive elderly woman presented with sudden
onset equal weakness upper limbs and lower limbs of
right side associated with slurring of speech and
deviation of angle of mouth towards left side
• No sensory deficits.
• No history suggestive of other cranial nerves,
cerebellum , brain stem involvement
• The history is suggestive of acute neurological deficit
probably due to thrombotic( ischemic ) stroke in the
posterior limb of left internal capsule due to thrombus in
left middle cerebral artery territory
EXAMINATION
GENERAL PHYSICAL EXAMINATION
Patient was conscious ,cooperative and well oriented to
time place and person
Patiently was moderately built and nourished
Pallor: absent
Icterus : absent
Cyanosis: absent
Clubbing : absent
Lymph node enlargement : absent
Edema : absent
• Height : 160 cm
• Weight : 58 kgs
• BMI :22.7 kg/m2
• Thyroid and spine : appears to be normal
• No evidence of ptosis , squint
• No engorged veins in neck
• No evidence of xanthoma
• No evidence of acanthosis nigricans
VITALS
Pulse: 72 beats per minute, regular in rhythm, normal
volume, normal character; Arterial wall is non palpable
There is no radio- radial delay or radio- femoral delay.
• Blood pressure: 128/90 mm of hg measured on right
brachial artery in supine position
• Respiratory rate: 16 cycles per minute, predominantly
thoracoabdominal , no use of accessory muscles for
respiration.
• Axillary temperature of 98. 6 degree Fahrenheit
• JVP : NORMAL
A. Higher Mental functions:

• Right handed individual

• Conscious, co-operative well oriented to time, place and
person
• Appearance and Behaviour: Appropriate
Emotionally stable
• Memory : Recent, immediate, remote memory intact
• Calculation : normal
• Speech : fluency reduced ,repetition affected and the patient
uses lesser number of words while speaking but
comprehension is normal .
• Patient is not able to read and write
B . CRANIAL NERVE
EXAMINATION
CRANIAL NERVE RIGHT LEFT
I NORMAL NORMAL
II Visual acuity: Counting Visual acuity: Counting
finger at 6 metre finger at 6 metre
Visual field: Normal by Visual field: Normal by
confrontation technique confrontation technique
Pupil: Round and Pupil: Round and
reactive, 4mm in size reactive, 4mm in size
Colour vision: Normal Colour vision: Normal
Fundoscopy : not done Fundoscopy : not done
III,IV,VI Normal ocular motility Normal ocular motility
in all cardinal directions in all cardinal directions
Pupillary reflex: normal Pupillary reflex: normal
V Sensory: NORMAL Sensory: NORMAL
Motor: NORMAL Motor: NORMAL
Jaw jerk: Absent
CRANIAL NERVE RIGHT LEFT
FACIAL NERVE (VII) Forehead wrinkling : Forehead wrinking :
present present
Able to close eyes Able to close eyes
Loss of nasolabial fold Nasolabial fold :
present
Angle of mouth
Taste sensation in deviated to left side
anterior 2/3 rd normal Taste sensation in
anterior 2/3 rd : normal
VIII NORMAL HEARING NORMAL HEARING

IX,X Normal soft palate Normal soft palate

motility motility
No nasal regurgitation No nasal regurgitation
Gag reflex not Gag reflex not
performed performed

XI NORMAL POWER OF NORMAL POWER OF

sternocleidomastoid sternocleidomastoid
and trapezius and trapezius
C . MOTOR EXAMINATION
NUTRITION
PARAMETER RIGHT LEFT

ARM CIRCUMFERENCE 24 cm 24 cm

FOREARM 19 cm 19 cm

THIGH 33 cm 33 cm

CALF 25 cm 25 cm
 D . TONE OF MUSCLES
RIGHT LEFT

UPPER LIMB
[Link] Increased(spasticity ) NORMAL
[Link] Increased (spasticity) NORMAL

LOWER LIMB
[Link] Increased(spasticity) NORMAL
[Link] Increased (spasticity) NORMAL

• IMPRESSION:INCREASED TONE IN RIGHT UPPER AND LOWER LIMB( SPASTICITY )

C POWER
PARAMETER RIGHT LEFT
1. MOVEMENT AT
SHOULDER JOINT

FLEXION 3 5
EXTENSION 3 5
ABDUCTION 3 5
ADDUCTION 3 5
INTERNAL ROTATION 3 5
EXTERNAL ROTATION 3 5

2. MOVEMENT AT ELBOW
JOINT
3 5
FLEXION 3 5
EXTENSION
 RIGHT LEFT

3. MOVEMENT AT WRIST
JOINT 3 5
FLEXION 3 5
EXTENSION 3 5
ABDUCTION 3 5
ADDUCTION
4. MOVEMENT AT HIP JOINT
FLEXION 5
EXTENSION 3 5
ABDUCTION 3 5
ADDUCTION 3 5
EXTERNAL ROTATION 3 5
INTERNAL ROTATION 3 5
 RIGHT LEFT

5 .MOVEMENT AT KNEE
JOINT 3 5
FLEXION 3 5
EXTENSION
6. MOVEMENT AT ANKLE
JOINT 3 5
PLANTAR FLEXION 3 5
DORSIFLEXION
7. TOE MOVEMENTS
FLEXION 3 5
EXTENSION 3 5

• IMPRESSION : Reduced power in right upper and lower limb( movement

against gravity )
E. REFLEXES
SUPERFICIAL REFLEXES RIGHT LEFT

1. CORNEAL REFLEX PRESENT PRESENT

2. CONJUNCTIVAL REFLEX PRESENT PRESENT

3. ABDOMINAL REFLEX ABSENT PRESENT

4. PLANTAR REFLEX EXTENSOR RESPONSE FLEXOR RESPONSE

DEEP REFLEXES
RIGHT LEFT

BICEPS REFLEX 3+ 2+

TRICEPS REFLEX 3+ 2+

SUPINATOR REFLEX 3+ 2+

KNEE REFLEX 3+ 2+

ANKLE REFLEX 3+ 2+

• IMPRESSION : ABSENT SUPERFICIAL REFLEXES AND

EXAGGERATED DEEP TENDON REFLEXES ON RIGHT SIDE
[Link] SYSTEM EXAMINATION
PARAMETERS RIGHT LEFT

SPINOTHALAMIC
SENSATIONS
[Link] INTACT INTACT
[Link] INTACT INTACT
[Link] TOUCH INTACT INTACT
[Link] INTACT INTACT

POSTERIOR COLUMN
SENSATIONS
[Link] TOUCH INTACT INTACT
[Link] INTACT INTACT
[Link] SENSE INTACT INTACT
PARAMETERS RIGHT LEFT

CORTICAL
SENSATIONS Intact Intact
[Link] localization Intact Intact
[Link] point Intact Intact
discrimination Intact Intact
[Link]
[Link]

• IMPRESSION : NO SENSORY DEFICITS

E. CEREBELLAR FUNCTION
TESTS
Titubation: Absent
Nystagmus: Absent
Scanning speech: absent
Dysmetria/Past pointing: absent
Dysdiadochokinesia: normal
Intention tremor: Absent
Rebound phenomenon: Absent
Pendular knee jerk: Absent
Impression: No signs of cerebellar dysfunction present
F. Signs of Meningeal Irritation: Absent
G. Examination of Skull and Spine: Normal
H. Auscultation of the Neck And Over The Skull:
1 No bruit over the skull
2. No carotid bruit
I. Stance and Gait: patient unable to stand or walk on
his own
• Cardiovascular System Examination : S1, S2 heard
• no palpable impulse
• no parasternal heave
• no cardiomegaly
• no murmurs heard
• Respiratory System Examination :Normal vesicular breath sounds
heard
air entry is equal on both side
no added sounds present

• Per abdomen Examination : Soft, non tender abdomen

• no dilated veins , scars over the abdomen
no organomegaly, bowel sounds could be
ausculated
PROVISIONAL DIAGNOSIS
• Clinical : Spastic hemiparesis of right upper and lower
limb with dysarthria and UMN type right side facial
nerve palsy
• Pathological : thrombotic ischemic stroke
• Anatomical : posterior limb of Left internal capsule
• Etiology : Elderly age ,post menopausal women,
hypertension
INVESTIGATIONS
• NON CONTRAST CT SCAN : to rule out hemorrhage
• MRI
• ANGIOGRAPHY : CT ANGIOGRAPHY OR MR
ANGIOGRAPHY
• ECG AND ECHOCARDIOGRAM
• BLOOD PROFILE AND COAGULATION PROFILE
MANAGEMENT
MEDICAL MANAGEMENT : prophylactic antibiotics
compression
stockings
Blood pressure control
Antipyretics if fever present
2. Secondary prevention of stroke : aspirin 75mg +
clopidogrel
3. atorvastatin : 80 mg
4. Lifestyle modifications
5. Rehabilitation : physiotherapy , speech therapy