1601006008 General medicine case

Hallticket no 1601006008
 

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Case -A 50yr old female ,farmer by occupation resident of suryapet came with chief complaints of weakness of left upper and lower limb since 3days

History of present illness

-patient was apparently asymptomatic 3 days ago and then she developed sudden onset of weakness is her left upper and lower limbs  which was recovering ,followed by fall with no history of trauma

There is slurring of speech and deviation of mouth to right side

No h/o bowel and bladder abnormalities,swallowing difficulty,blurring of vision

No h/o trauma,headache,nausea and vomiting

                                                       

Past history 

-no similar complaints in past 

-k/c/o hypertension since 5yrs and diabetes since 3yrs

No h/o epilepsy,asthma,copd,coronary artery disease ,blood transfusions,connective tissue disorders 

Family history 

-no relevant family history 

Menstrual history

She had undergone hysterectomy 4years back for fibroid uterus

Personal history

Diet-mixed

Appetite-normal

Bowel and bladder movements-regular

Sleep-adequate

Addictions-no addictions 

Treatment history 

Patient is on glimepiride for diabetes from 4years

General examination

Consent is obtained

A 50 yr old female patient ,supine decubitus who is moderately built and nourished is conscious ,coherent ,cooperative and comfortably lying on the bed,well oriented to time,place and person 

There is no pallor ,icterus,cyanosis,clubbing,koilonychia,generalised lymphadenopathy and no pedal Edema 

Vitals 

Temperature -afebrile

Pulse rate-74bpm with regular rhythm ,character and volume,no radiofemoral delay 

Blood pressure-110/85mmHg

Respiratory rate-16cpm

Systemic examination

Central nervous system examination

1)Intellectual functions

 -patient is conscious,oriented to time ,place and person

-memory-immediate,recent and remote memory present

-appearence-well kept

-speech-normal 

-right handedness

2)cranial nerves

Olfactory-smell present on both sides

Optic-visual acuity -6/6

    Visual field,colour vision,reflexes -normal 

3,4,6 cranial nerves-ocular movements -present

         Nystagmus,ptosis,Diplopia-absent

       Pupils are normal

Trigeminal -motor and sensory functions normal on both sides

 Facial nerve

Nerve is affected on left side

-deviation of mouth to right

-frowning present

-absent nasolabial folds on left side

-blowing and whistling absent

Taste sensation on anterior 2/3rd of tongue present

Corneal reflexpresent on both sides

Vestibulocochlear nerve-rinnes Weber,schwabach test normal on both sides

Vagus and glossopharyngeal -gag reflex present,uvula midline

Spinal accessory-shrugging of shoulders present

Hypoglossal-no deviation of tongue

3)Motor system

A)attitude and position-extension of Lt lower leg

B)bulk-no wasting

C)tone-Rt        Lt

UL        N          N

LL         N          N

D)power-

UL  Rt     Lt

      -5/5    -0/5

LL  -5/5     4/5

4)Reflexes

Superficial             Rt         Lt

  Corneal              +2          +2

 Conjunctival       +2            +2

Abdominal         +2               +2        

Plantar                flexor       extensor

Deep                Rt             Lt

Biceps             +2           +2

Triceps            +2             +2

Supinator         +2            +2

Knee              +2                +2

Ankle              0                 0

5)Sensory system  

Superficial -fine touch,temperature,pain -present

Deep-position,vibration,crude touch,stereognosis,2point discrimination- present 

6)Cerebellum 

Speech,nystagmus,ataxia,tremors-absent

7)Coordination and gait

Finger nose test ,finger finger test,heel knee test-present

Gait -dragging type

 Romberg test -negative

8)signs of meningeal irritation

Nuchal rigidity,kernigs and brudzinski’s sign - absent

Investigations

Ct normal,taken within 1hr of onset of symptoms

Showing its not hemorrhage 

Other systems

CVS-s1,s2 heard ,no murmurs ,k/c/o valvular heart disease,atrial fibrillation

Ecg findings normal

Respiratory-Normal vesicular breath sounds,bilateral air entry present

Git-no significant findings

Differential diagnosis

-Cerebral embolism

-Subarachnoid hemorrhage

-cerebral hemorrhage 

-ICSOL

Treatment received till now

-atorvastatin

-ecospirin

-clopidogrel

Provisional Diagnosis-

Left Sided hemiparesis with left UMN type facial