CNS Clinical Case Discussion
- Akshaypravwin K G
2017 batch
Mr. Palani a 45 yrs. Old male, studied 8th Std. is a
daily waged construction labourer by occupation,
belonging to upper-lower socio-economic class (IV),
residing in Washermenpet came to Stanley hospital
with Chief Complaints of,
.H/o Inability to use left Upper and Lower limb
.H/o deviation of angle of mouth to right side
.H/o Chest pain, palpitation, increased sweating
• H/O Presenting complaints,
The patient was apparently normal 3 months back.
On the day of event morning he woke up at 6 am and was getting
ready for his work, he suddenly felt chest pain and started
sweating more than the usual, after few mins. he felt his heart
racing for sometime so he laid down in bed to relax,
after it stopped when he tried to get up from the bed, he noticed
that he was not able use his left upper and lower limb.
So he called his son for help to get up from the bed, and his son
admitted him in Stanley Medical hospital about 8 am in the
morning.
The patient presented with,
Left side Upper limb and Lower limb Equal weakness
. Sudden in onset
. Non progressive
H/O Chest pain, palpitation, increased sweating
. Acute in onset
. Relieved on rest
H/O Fever
. 3 month back
. Moderate grade fever
. Associated with joint pains
. Visited nearby clinic and was prescribed some tabs.
H/o difficulty in,
Getting up from bed
Buttoning his shirt
Combing his hair
Griping his slippers
Lifting head from pillow
He could roll over the bed
He felt both of his upper limb and lower limb to be heavy
No H/O Headache/blurring of vision
No H/O Nausea/vomiting /diarrhoea
No H/O Epilepsy
No H/O sensory disturbances
No H/O involuntary movements
No H/O loss of sense of smell (I)
No H/O visual disturbances (II)
No H/O double vision, difficulty in eye movements (III,IV,VI)
No H/O sensory loss over the face, difficulty in chewing (V)
No H/O hard of hearing, vertigo and tinnitus (VIII)
No H/O nasal twang or nasal regurgitation (IX,X)
No H/o difficulty to shrug shoulder/Rotate neck (XI)
No H/o dysarthria/difficulty to protrude the tongue out(XII)
No H/o ANS disturbances
No H/o higher function disturbances
No H/o Loss of consciousness
Past History,
H/o Similar episodes of Chest pain, palpitation, increased
sweating
. One month back
. Visited nearby clinic and was prescribed some tabs.
H/O Fever
. 3 month back
. Moderate grade fever
. Associated with joint pains/ pharyngitis
. Visited nearby clinic and was prescribed some tabs.
. Similar epsodes in childhood which was not treated
A Known Case Of Type - II Diabetes Mellitus and
Hypertension for past 10 yrs,
Not a known case of TB/COPD/Epilepsy/Jaundice
No H/O of TIA/ RIND
No H/O trauma/ any visual disturbances /ear discharges
No H/o recent bites /vaccination
No H/o venereal disease
No H/O recent surgery
Personal History,
. Consumes mixed diet
. Normal bowel and bladder movements
. Normal sleep pattern
. H/o Smoking cigarette and alcohol intake,
. Smoking index <100 (5 CPD x 20 yrs.)
. Pack years – 2.5 pack years (.25 packs/day x 20 yrs.)
. Consumes 250ml of brandy/week
. No h/o food/medication allergy
Treatment History,
. On Anti-hypertensives and Oral hypoglycemic agents
for 10 years but takes medications irregularlly.
. Visited nearby clinic and was prescribed some tabs. for
fever before 3 months
Family history,
. History of similar fever epiodes associated with joint
pains in the family in childhood.
. Patient’s brother has a history of diabetes mellitus for
the past 20 years
Summary,
Mr. Palani 45 yrs old ,a daily waged construction
labourer by occupation from Washermenpet , presented
with a sudden onset of impairment on the left upper
and lower limb with angle deviation of mouth to the
right with chest pain, palpitation, increased sweating.
He is a occasional smoker and a known case of diabetic
& hypertensive on irregular treatment
According to the history , the most probable system
involved is CNS.
General Examination,
The patient was examined after obtaining informed consent
under bright light.
. The patient is Conscious, Comfortable, Oriented to
time,place,person. Moderately Built and Nourished.
. No Pallor/Jaundice/Clubbing /Cyanosis /Pedal Edema/
Significant Generalised lymphadenopathy.
Vital Signs,
. Pulse : 90 beats/min ( Rapid Rate, Irregular Rhythm, Normal
Volume, Character, felt in all palpable peripheral vessels, no
Radio femoral delay)
. BP : 130/80 mmHg (In Right limb,sitting posture)
. RR : 20 breaths/min
. Temperature : Afebrile
Examination of CNS,
HIGHER MENTAL FUNCTIONS:
Conscious, Coherent and Co-Operative
Oriented to time,place,person
Appearance and Behaviour : Appropriate
Emotionally stable
Memory : Intact
Intelligence Normal
Right handedness
Speech output : Normal
CRANIAL NERVES
CRANIAL RIGHT LEFT
NERVES
I Normal Normal
II Normal Visual acuity/Field of Normal Visual acuity/Field
vision/ Field of vision of vision/ Field of vision
III , IV , VI .Normal extra ocular motility .Normal extra ocular
in all cardinal directions. motility in all cardinal
.Normal Pupilary Reflex directions.
.Normal Pupilary Reflex
CRANIAL
NERVES
RIGHT LEFT
V Normal Normal
VII •Upper Quadrant of face is Normal
normal.
•Angle of mouth deviated
to the right side.
•Taste over Ant. 2/3rd
decreased.
•Can’t retain air in mouth.
VIII Normal Normal
IX , X Normal Normal
XI , XII Normal Normal
MOTOR SYSTEM
1) NUTRITION :
BULK OF MUSCLE RIGHT LEFT
1 INSPECTION No visible No visible
wasting wasting
2 PALPATION : Arm 34cm 33cm
10cm from acromion
PALPATION : Forearm 27cm 26cm
10cm from olecranon
PALPATION : Thigh 54cm 52cm
18cm above patella
PALPATION : Leg 41cm 40cm
10cm below patella
2) TONE
TONE RIGHT LEFT
1 UPPER LIMB Normal Clasp-knife
Spasticity
2 LOWER LIMB Normal Clasp-knife
Spasticity
3)POWER OF THE MUSCLE
Parameter RIGHT LEFT
Movement at shoulder joint
•Flexion 5 2
•Extension 5 2
•Abduction 5 2
•Adduction 5 2
•Internal Rotation 5 2
•External Rotation 5 2
Movement at elbow joint
•Flexion 5 2
•Extension 5 2
RIGHT LEFT
Movement at Wrist Joint
•Flexion 5 2
•Extension 5 2
•Abduction 5 2
•Adduction 5 2
Movement at Hip Joint
•Flexion 5 2
•Extension 5 2
•Abduction 5 2
•Adduction 5 2
•External Rotation 5 2
•Internal Rotation 5 2
RIGHT LEFT
Movement at Knee joint
•Flexion 5 2
•Extension 5 2
Movement at Ankle joint
•Plantar flexion 5 2
•Dorsiflexion 5 2
Toe Movements
•Flexion 5 2
•Extension 5 2
REFLEXES
REFLEX RIGHT LEFT
Superficial Reflex
•Corneal Reflex Not done Not done
•Conjunctival Reflex Present Negative
•Abdominal Reflex Present Lost
•Cremasteric Reflex Not done Not done
•Plantar Reflex Flexor Extensor (Babinski sign +)
Deep Reflex
•Biceps Reflex Normal Exaggerated
•Supinator Reflex Normal Exaggerated
•Triceps Jerk Normal Exaggerated
•Knee Jerk Normal Exaggerated Grade 3
•Ankle reflex Normal Exaggerated
SENSORY SYSTEM
RIGHT LEFT
Spinothalamic sensations
•Pain Intact Intact
•Temperature Intact Intact
•Deep touch Intact Intact
•Pressure Intact Intact
Posterior Column sensations
•Fine touch Intact Intact
•Vibrations Intact Intact
•Joint sense Intact Intact
Cortical sensations
•Tactile localization Intact Intact
•Two point discrimination Intact Intact
•Stereognosis Intact Intact
CEREBELLAR FUNCTION TEST
RIGHT LEFT
UPPER LIMB
Finger nose test/ Finger- Normal Could not be tested
Finger nose test
Diadochokinesia Normal Could not be tested
Drawing a circle in the air Normal Could not be tested
LOWER LIMB
Heel knee test Normal Could not be tested
Draw a circle in air Normal Could not be tested
Tandem walking Normal Could not be tested
•Nystagmus : Absent
•Intention tremor : Absent
•Rebound phenomenon : Absent
• No involuntary movements/tremors
• There are no signs of meningeal irritation
• The patient can walk only few steps without
support
• Circumduction gait is observed
• Examination of Skull and Spine : Normal
• Examination of ANS : Increased Sweating
Other systemic examination
Cardiovascular System Examination :
• S1 S2 heard
• opening snap heard, Mid diastolic murmurs heard.
Respiratory System Examination :
• Normal vesicular breath sounds on all areas , no
added sounds
Abdomen Examination :
• Soft , Non tender
• No organomegaly
Diagnosis
• Complete Spastic Left sided Hemiplegia with
UMN facial palsy probably due to
thromboembolic occlusion of the lenticulate
striate branch of middle cerebral aretery
supplying the posterior limb of the internal
capsule region caused by atria fibrillation a
complication of the Rheumatic Heart Disease
Investigations
• CBC
• RBS/HbA1c
• Lipid/Coagulation profile
• Thyroid (Hyperthyroidism) Function test
• Liver Function tests
• Throat swab/ ASO titer
• ECG (AF)
• ECHO/Chest X-Ray
• CT (Hemorrhagic)/ MRI Brain (Ischemic)
• CT/MRI Angiography
Management
• Take Antihypertensive and Oral hypoglycemic
drugs regularly
• Antibiotics (preventive & prophylactic therapy)
• Ca Channel blockers
• Anticoagulation therapy with aspirin
• Angioplasty and Stenting , Clot extraction if
needed
• Physiotherapy (4B’s of hemiplegia care)
• Motivate the patient to follow a healthy
lifestyle and ask him to take drugs properly
