CASE PRESENTATION

Devadharshni. M
Sathyaprabaa.S.T
Sneha.M
DEMOGRAPHIC DETAILS:
• Name :Mrs X
• Age :54 years
• Sex : Female
• Address : Kulashekaram
• Occupation : Housewife
• Informant : Son( reliable)
CHIEF COMPLAINTS:
• Difficulty in walking
• Slurring of speech
One month
• Deviation of angle of mouth to left
• Inability to close right eye
HISTORY OF PRESENTING ILLNESS:
• Mrs X 54 year old lady who is a known hypertensive with
poor drug compliance was apparently normal one month ago.
One evening by 6:45 pm, while attending a church gathering she
developed headache which is acute in onset,severe in intensity,
crushing type, involving the whole head, associated with
heaviness of head followed by sensation of rotation of
surrounding, blurring of vision lasting for 1-2 sec immediately
followed by a fall. There was no head injury.
• She was then carried by attender in an auto to nearby
hospital. On the way she developed cough while drinking water
and vomited ,which contained only food particles.
• In the hospital she had some difficulty in lifting up her left
upper and lower limbs. But could move her right limbs normally.
• Then they noticed her speech was slurred and angle of
mouth deviated to left side. She was referred to higher centre
where brain imaging was done followed by treatment and she
improved.
• Bystander attempted to make her walk to bathroom with
support,but she had unsteadiness on walking and she was
swaying to left side. That night bystander noticed that she was
unable to close her right eye.
The next day,
• She swayed to left on sitting
• She had difficulty in holding objects in left hand, difficulty in
buttoning and unbuttoning her dress.
• Bystander noticed outward deviation in her left eye.
• After 4 days, she started to walk with the help of bystander.
Her swaying reduced. She had difficulty in maneuvering left foot
into the slippers and they noticed slippage of slippers from her left
foot. Then she got discharged.
• 3-4 days after discharge, while watching television she had
double vision which disappeared on closing one eye and improved
after 2weeks.
• All other symptoms improved but swaying to left side,
slurring of speech and deviation of angle of mouth to left
persisted.She then brought here for further management.
• There was no h/o loss of consciousness,convulsions and memory
disturbances.
• There was no h/o loss of smell ,loss of vision, drooping of
eyelids,loss of sensation over face ,loss of taste, ear pain or
discharge , hoarseness of voice , nasal regurgitation.
• There was no h/o buckling of knees while walking, difficulty in
turning from side to side, there was no heaviness of limbs.
• There was no h/o loss of sensation, difficulty in appreciating hot
and cold, difficulty in appreciating sensation of clothes over
body, cotton wool sensation,pin needle sensation, burning
sensation and tingling.
• There was no increase in swaying while closing eyes for washing
face.
• There was no h/o loss of bowel control , constipation and
diarrhoea.
• There was no h/o increased frequency of micturition,urgency,
dripping of urine ,painful micturition.
• There was no h/o tremulousness of limbs while reaching out for
objects. No h/o smearing of face with food.
• There was no h/o abnormal posturing, violent flinging movements
of limbs,dance like movements.
PAST HISTORY:
• No h/o similar episodes in the past.
• K/c/o hypertension for past 2 years and is on irregular medication
TAB ENALAPRIL 5mg BD
• Not a k/c/o diabetes
• No h/o dyslipidaemia ,bronchial asthma , epilepsy , tuberculosis.
• No h/o cardiac disease , any other drug intake, previous surgery,
bleeding diathesis, blood transfusion.
PERSONAL HISTORY:
• Non veg diet
• Not a smoker , not an alcoholic
• No bowel and bladder disturbances
• No sleep disturbances

MENSTRUAL HISTORY:
• Attained menarche at 15 years of age.
• Married at 21 years of age.
• First child birth at 23 years.
• Menopause at 50 years of age.
SUMMARY :
A 54 year female patient, known hypertensive for 2 years
and with poor drug compliance. One month back, she developed
headache, vomiting, blurring of vision followed by a fall . She had
difficulty in lifting up her left upper and lower limbs, slurring of
speech and angle of mouth deviated to left side for which she
got admitted and treated in a nearby hospital. That night, they
noticed that she was unable to close her right eye.
Next day, she swayed to left while walking with support as well
as in sitting posture. She had difficulty in holding the object in left
hand.
The patient had diplopia and outward deviation of left eye.
 All other symptoms improved but swaying to left,
slurring of speech and deviation of angle of mouth to
the left persisted. She then brought here for further
management .

From the above history,

The probable diagnosis is Acute stroke syndrome .
Posterior circulation stroke – Ischemic / Hemorrhagic?
GENERAL EXAMINATION:
• She is conscious, cooperative, oriented to time ,place and
person, comfortable, moderately built and nourished.
• No pallor, icterus,clubbing, cyanosis, significant generalised
lymphadenopathy , edema.
• No neuro cutaneous markers.
VITALS:
• Pulse rate : 68 bpm, regular rhythm, normal volume, no specific
character, no radio-radial and radio-femoral delay. All peripheral
pulses felt equally on both sides, condition of vessel wall normal.
• Carotids felt normally on both sides.
• Blood Pressure: 140/100 mmHg in left upper limb on supine
position.
• Respiratory rate : 16 breaths/min ,thoracoabdominal
• Temperature: 98.6°F
• JVP : Normal
EXAMINATION OF NERVOUS SYSTEM

Higher mental functions:

• Handedness : Right
• Educational status : 7 th standard
• Occupation : Home maker
• Knowledge of language : Malayalam, English
• Level of consciousness : conscious & oriented
• Attention : alert & attentive
• Memory : recent, remote, immediate- intact
Speech: Slurred
Frequency –Impaired
Comprehension- intact
Repetition- able to do
Naming – able to do
Reading- able to do
Writing- able to do
Calculation : able to do
Intelligence : normal
Appearance : well groomed
Delusion, hallucination: absent
CRANIAL NERVE EXAMINATION:
RIGHT LEFT

1. Olfactory nerve Intact Intact

2. Optic nerve
Visual acuity Normal Normal
Visual field Normal Normal
Colour vision Normal Normal
Fundus - -
 RIGHT LEFT
3,4,6.
Occulomotor, trochlear,
abducent
Eyelid & eye
Lid retraction Normal Normal
Ptosis Absent Absent
Squint Absent Divergent squint
Diploia Binocular diplopia disappers on closing either
one of both eyes.

Convergence Intact Intact

 RIGHT LEFT
Eyeball movements Bilateral vertical eye movements preserved.

1 ½ syndrome

On looking to right
- Conjugate
horizontal gaze Cannot abduct Cannot adduct
palsy

On looking to left
- Internuclear Adducts minimally Nystagmus

ophthalmoplegia
 RIGHT LEFT

Nystagmus Absent Present on abducting

Jerky, Horizontal

Pupils
Size 3mm 3 mm
Shape Round Round
Equality Equal Equal
Light reflex – direct Intact Intact
Indirect Intact Intact
Accomodation Intact Intact
 RIGHT LEFT
5. Trigeminal nerve
Sensory (pain,touch,
Temperature)
Ophthalmic, maxillary, Intact Intact
mandibular

Motor
Temporalis No wasting No wasting
Masseter No wasting No wasting
Pterygoids Intact Intact

Reflexes
Corneal Absent Present
Conjunctival Absent Present
Jaw jerk
Absent
 RIGHT LEFT
7. Facial nerve
Motor
Wrinkling of forehead Absent Present
Blinking Absent Present
Bells phenomenon Present Absent
Forced eye closure Not able to do Intact
Nasolabial fold Lost Intact
Smile / show teeth Not able to do Intact
Blow cheek Not able to do
Whistling Not able to do
Platysma Affected Intact
Involuntary movements Absent Absent
 RIGHT LEFT

Stapedius
Hyperacusis Absent Absent
Secretomotor
Xerosis of eye Present Absent

Special sensation
Taste in anterior 2/3rd Lost Intact
of tongue
Somatic sensation
External auditory canal Absent Absent

Right LMN facial palsy

 RIGHT LEFT
8. Vestibulocochlear
nerve
External auditory canal
Ear wax / pain /discharge Absent Absent

cochlear part
Rinnie’s test Positive Positive
Webers test Lateralised to left ear
ABC test Not done

Vestibular part
Tinnitus, vertigo Absent
nystagmus Absent present on abduction
 RIGHT LEFT

9,10 Glossopharyngeal,
vagus
Normal
Pitch, quality of sound Normal
Central
Uvula position
palatal movements Bilaterally equal
Gag reflex Present Present
Palatal reflex Present Present
11. Accessory nerve
Trapezius Intact Intact
Sternomastoid Intact Intact
 RIGHT LEFT

12. Hypoglossal nerve

TONGUE
Wasting Absent Absent
Fasiculations Absent Absent
Fibrillations Absent Absent
Tongue protrusion Absent Absent
Power Normal Normal
MOTOR SYSTEM EXAMINATION:
Atitude of limbs – normal
No visible wasting

BULK RIGHT LEFT

(cm) ( cm)
Upper limb
. Arm 28 27.5
. Forearm 22 22

Lower limb
. Thigh 47.5 47.5
. Leg 29.5 29
TONE RIGHT LEFT

Upper limb
. Shoulder
Normal
. Elbow Normal
. Wrist
Lower limb
. Hip
Normal Normal
. Knee
. Ankle
POWER RIGHT LEFT

Upper limb
1. Shoulder
. Flexion 5/5 5/5
. Extension 5/5 5/5
. Abduction 5/5 5/5
. Adduction 5/5 5/5
. Internal rotation 5/5 5/5
. External rotation 5/5 5/5
2. Elbow
. Flexion 5/5 5/5
. Extension 5/5 5/5
3. Wrist
. Flexion 5/5 5/5
. Extension 5/5 5/5
. Abduction 5/5 5/5
. Adduction 5/5 5/5
POWER RIGHT LEFT

Lower limb
1. Hip
Flexion 5/5 5/5
Extension 5/5 5/5
Abduction 5/5 5/5
Adduction 5/5 5/5
External rotation 5/5 5/5
Internal rotation 5/5 5/5
2. Knee
Flexion 5/5 5/5
Extension 5/5 5/5
3. Ankle
Dorsiflexion 5/5 5/5
Plantarflexion 5/5 5/5
REFLEXES RIGHT LEFT

Superficial reflexes
Corneal, conjunctival Absent Present
Gag , Palatal Present present
Abdominal Present Present
Plantar Flexor Flexor

Deep reflexes
Jaw jerk Absent
Biceps,Triceps, Normal Normal
Supinator Normal Normal
Knee jerk Normal Normal
Ankle jerk Normal Normal
 SENSORY SYSTEM EXAMINATION:
RIGHT LEFT

Sensory
Spinothalamic sensation
INTACT
(pain,temperature, crude INTACT
touch)
Posterior column sensation
( position sense, joint
sense, vibration, fine touch)
Cortical sensation
Tactile localisation
Two point discrimination INTACT INTACT
Graphaesthia
Stereognosis
COORDINATION SYSTEM:
CEREBELLAR SIGNS RIGHT LEFT

• Finger nose test Negative – Able to do Positive – Not able to do

• Finger to finger nose Negative Positive
test
• Heel knee test Negative Positive
• Dysdiadochokinesia Absent Present
• Rebound Absent Absent
phenomenon
• Tandem walking Impaired
• Involuntary
movements Absent Absent

GAIT – Reels to left side

AUTONOMIC NERVOUS SYSTEM – Normal

PERIPHERAL NERVES – Normal

SIGNS OF MENINGEAL IRRITATION – Absent

SKULL , SPINE – Normal

CAROTIDS - Normal
OTHER SYSTEM EXAMINATION:
Cardiovascular system examination :
S1,S2 heard normally in all areas. No added sounds /murmurs.

Respiratory system examination :

Chest movements bilaterally equal.
Normal vesicular breath sounds in all areas.
No added sounds.
Per abdomen examination:
Soft, non tender abdomen.
No organomegaly.
SUMMARY:
• A 54 year female patient known hypertensive came with
complaints of swaying to left side, slurring of speech, deviation of
angle of mouth to left for one month.
• Examination reveals
Conjugate horizontal gaze palsy on looking to right side.
Internuclear ophthalmoplegia on looking to left side.
Involvement of facial nerve in the form of Right LMN facial palsy.
Cerebellar signs present.
 Functions lost Structures affected

1 Swaying to left Left sided Cerebellar connections

Deviation of angle of mouth to left, Right sided 7th cranial nerve

2
inability to close right eye nucleus (LMN)
7+1½ =8½
Right sided
Paramedian Pontine Reticular SYNDROME
Conjugate horizontal gaze palsy on
Formation(PPRF)
looking to right
3 +
Internuclear ophthalmoplegia on
Medial Longitudinal Fasciculus
looking to left
(MLF)
DIAGNOSIS:
It is a case of Acute stroke syndrome
Posterior circulation stroke – Ischemic / Hemorrhagic?
Site of lesion: Brainstem probably Right sided INFERIOR PONS
Structures involved are : Left Cerebellar connections , Right 7th
cranial nerve nucleus, Right sided Medial Longitudinal Fasciculus
and Paramedian Pontine Reticular Formation.
Artery involved : Basilar artery
Risk factor : Hypertension