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CNS Case Presentation

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Chiranth N
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7 views20 pages

CNS Case Presentation

Uploaded by

Chiranth N
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as KEY, PDF, TXT or read online on Scribd
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CLINICAL CASE

PRESENTATION
Chief complaints:

Generalised weakness since 3 days


PATIENT DETAILS

Name: Tajunnisa
Age/Sex: 40/F
Address: Kodagu
Occupation: Housewife
Education: 7th std
Handedness: Right handed
DOA: 15/09/23
DOE: 18/09/23
History of presenting illness
Patient was apparently normal and performing her daily
routine activity 3 days back.
Then she developed generalised weakness while cooking
which is more on left side ie.both upper limb & lower
limb.following weakness she was unable to hold the glass of
water,comb her hair,she has difficulty in squatting and
gripping her slipper.she also complains of vomiting which was
sudden in onset,non projectile,non blood tinged,non bilious,
and containing food particles.
It was associated with blurring of vision
No h/o twitching ,tremors,speech disturbances
No h/o of disturbance in smell
No h/o diplopia,squint,ptosis
No h/o of difficulty in eating
No h/o of drooling of saliva,deviation of
mouth,inability to close eye,loss of taste sensation
No h/o of difficulty in turning head
No h/o of retention of urine
No h/o of chest pain,breathlessness,palpitation
No h/o of fever,cough,cold,wheezing
No h/o trauma
No h/o loss of appetite,loss of weight
Past history
K/c/o Hypertension since 2 yr On medication
Telmisartan 20 mg. 1-0-0

Family history
No similar complaints in the family
Personal history
Diet: Mixed
Appetite : normal
Sleep: adequate
Bowel and bladder: Normal and Regular
No h/o of smoking and Alcohol
Summary
A 40yr old woman who is known case of Hypertension
since 2 yrs presented with sudden onset of Generalised
weakness since 3 days which is more on left side
associated with vomiting and blurring of vision.
GENERAL PHYSICAL EXAMINATION
Patient was moderately built and nourished, conscious,
cooperative , well oriented to time, place and person.
Vitals:
Pulse:80 beats per minute ,regular rhythm,normal
volume and character,no vessel wall thickening,no
radio-radial delay
Bp: 140/80 mmhg check in right arm in sitting position
RR: 16cpm
Patient is afebrile
No pallor,Icterus,cyanosis,clubbing,lymphadenopathy,edema
CNS Examination
Higher mental function:
Patient is conscious,cooperative,well oriented to time,
place and person
Memory:recent , immediate, and remote memory is
intact.
Speech: fluent
Patient is able to read and write.
Cranial nerve examination: All the cranial nerves are
intact

Motor examination :
Nutrition:
Right. Left
Tone of muscle:
Power:
Reflexes:
Superficial reflexes:superficial reflexes are intact
bilaterally.
Deep tendon reflexes:
Sensory system : Intact
Cerebellar function tests:
Dysdiadokinesia: Absent
Ataxia: Absent
Nystagmus: Absent
Intention tremor: Absent
Pendular knee jerk : Absent
Rebound phenomenon : Absent
No signs of meningeal irritation
Other system Examination
CVS: S1 S2 heard , no murmur
RS: Normal vesicular breath sound heard , no added
sounds
Per Abdomen: soft , non tender, no organomegaly

Provisional diagnosis:
Right sided CVA
Thank you

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