GENERAL MEDICINE

CASE PRESENTATION

GREESHMA.C
ROLL NO 26
PRELIMINARY DATA

• Name : Mr.Selvam
• Age: 62 yrs
• Sex: Male
• Handedness: Right handed
• Education : 12 th std
• Occupation: Painter
• Socioeconomic status: lower middle class
• Address : Madhuranthagam
CHIEF COMPLAINTS:

• Weakness of the right upper and lower limb for 3 days

• Deviation of mouth towards left side for 3 days
 HISTORY OF PRESENTING ILLNESS:

• Patient was apparently normal before 3 days and he

developed weakness over the right upper and lower limbs.
• He first noticed the weakness at work ,when he could not
hold the paintbrush properly and was dropping it
frequently. It was gradual in onset and progressive. Initially
the weakness was present over the right upper limb and
then he developed weakness over the lower limb as well.
The weakness was not complete.
• He also noticed deviation of mouth to the left side
• There was no loss of consciousness
• He was then brought to the hospital
History related to motor system:

• Upper limb:
PROXIMAL MUSCLE:
• H/o difficulty in combing and lifting right hand above the
head
DISTAL MUSCLE :
• H/o difficulty in buttoning/unbuttoning the shirts
• Not able to mix food
• H/o difficulty in doing fine movements(writing/holding
objects/painting)
Lower limb
PROXIMAL MUSCLES:
• H/o difficulty in standing, walking, climbing stairs
DISTAL MUSCLES
• No H/o difficulty in holding the slippers

Trunk
• No h/o difficulty in turning in bed from side to side
• No h/o difficulty in lifting head from bed
History related to sensory loss:

• Able to appreciate cloth sensation

• Able to appreciate pain and prick sensation in the form
of Injection and mosquito bite
• No H/o numbness present
• No h/o loss of sense of temperature
 CRANIAL NERVES HISTORY
• I - No h/o loss/altered sensation of smell
• II - No h/o visual disturbances
Able to differentiate colors
no h/o difficulty in near vision
no h/o difficulty in distal vision
• III, IV,V – No h/o diplopia , squint ,drooping of eyelids
nystagmus.
• V- No h/o loss of sensation over the face and chewing
disturbances
VII-
• h/o facial asymmetry -deviation of angle of mouth to left
side
• h/o drooling of saliva on right side
• No h/o loss of taste
VIII
• No h/o hearing loss,
• No h/o vertigo/ giddiness
• No h/o ringing sensation in year
IX,X-
• No h/o nasal regurgitation
• No h/o aspiration
• No h/o dysphagia
• No h/o hoarseness of voice.
XI-
• No h/o difficulty to shrug shoulder /rotate neck
XII-
• No H/o dysarthria present
• No h/o difficulty in moving the tougue from side to
side inside the mouth
 AUTONOMIC NERVOUS SYSTEM

• No h/o constipation or loss of bowel control

• No h/o difficulty in initiation or control of urination
• No h/o dribbling of urine
• No h/o paroxysmal sweating
• No h/o involuntary movements
History related to etiology:

• No h/o of trauma
• No h/o fever and pain in neck
• No h/o headache, projectile vomiting, blurring of
vision , sleeping disturbance
• No h/o seizures
• No h/o chest pain and palpitations, breathlessness
• No h/o bleeding disorders
 PAST HISTORY

• No h/o similar episodes in the past

• He is a known case of hypertension for the past 3 years
and is on medication
• No h/o Diabetes mellitus ,Hyperlipidemia, TB, STDs,
Bronchial asthma
• No h/o recurrent headache, vomiting, diarrhoea, fever
• No h/o ischemic heart disease, epilepsy, trauma
• No h/o of surgery.
 PERSONAL HISTORY

• He consumes mixed diet

• No disturbance in sleep
• Normal bladder and bowel habits
• He is a smoker for past 20 years .He smokes 8-10
cigarettes per day
• Pack year= 10 pack years
• He does not consume alcohol
 FAMILY HISTORY

• No h/o similar complaints in the family

 SUMMARY
• 62 yr old right handed painter, Mr.Selvam is a known case
of hypertension for the past 3 years and a smoker for the
past 20 years , presented with weakness which was
gradual in onset and progressive, with unequal
involvement of the right upper and lower limb along with
left sided deviation of the angle of mouth.
• Probable pathology is vascular insult i.e thrombosis
involving a vessel supplying the left internal capsule with
involvement of facial nerve on same side and probable
etiology is old age , hypertension, smoking
• So the probable system involved is CNS
 EXAMINATION
GENERAL EXAMINATION:
• Patient is conscious, cooperative ,oriented to time, place
and person
• Moderately built and nourished
• No h/o pallor
• No h/o icterus
• No h/o clubbing
• No h/o cyanosis
• No h/o pedal edema
• No h/o lymphadenopathy
• Neurocutaneous markers are absent
 VITALS
Temperature - Afebrile
Pulse - 84 beats/min
• normal rate
• Regular rhythm
• Normal volume & character
• no radio femoral delay/radio radial delay
• no pulse deficit
• All peripheral pulses are felt equally on both sides
• No thickening of vessel wall
BP - 142/88 mm Hg measured in the left upper limb in
supine posture
RR- 17 breaths/min , abdominothoracic type
JVP not raised
EXAMINATION OF CNS
HIGHER MENTAL FUNCTION:

• The patient is conscious and well oriented to time, place,

person
• Immediate, recent, long term memory intact
• Speech output– slurred speech, fluent, comprehensive,
repeating normal
• The patient is right handed
• Emotionaly stable
Cranial nerves examination
I-Olfactory nerve
Right Left
Clove + +
Peppermint + +
Asafoetida + +

II-Optic nerve
Right Left
Visual Acuity 6/6 6/6
Field of vision Normal Normal

Colour vision Normal Normal

Fundoscopy Normal Normal
Pupillary reflex
Direct reflex Present Present
Indirect reflex Present Present
III,IV,VI (Occulomotor, Trochlear, Abduscent nerve)
Right Left
Extra ocular Normal Normal
movements
Pupil size 3mm 3mm
Pupillary reflex
Direct reflex Present Present
Indirect reflex Present Present

Accommodation reflex Present Present

• No nystagmus
• No ptosis
V- Trigeminal nerve

Right Left
Sensation over face Normal Normal
and buccal mucosa
Clenching of teeth Normal Normal

Corneal reflex + +
Conjunctival reflex + +
Jaw reflex Present Present
VII – Facial nerve
• Motor function
Right Left
Wrinkling of Normal Normal
forehead
Closure of eyes + +
Nasolabial fold Obliterated Normal

Angle of mouth is deviated to left side

• Sensory
▪ Taste in anterior 2/3 of tongue present
▪ Sensation over the tongue is present
• Reflexes
Reflex Right Left
Corneal + +
Conjunctival + +

• Secretomotor
▪ Salivary secretion is present
▪ Lacrimation is present
VIII - Vestibulocochlear nerve
Right Left
Rinne’s test + +
ABC test Normal Normal
Fistula test - -

• Weber’s test - no lateralisation

• No vertigo

IX, X – Glossopharyngeal ,Vagus Nerve

Taste sensation in the posterior 1/3 rd of tongue present
• Palatal reflex is present
• Palatal arch is equal on both sides
• Uvula is in midline
• Gag reflex is present
• XI - Spinal accessory Nerve
Right Left
Shrugging of shoulder present Present
Turning head against Normal normal
resistance
• XII - Hypoglossal Nerve
• Tongue is in midline
• Able to protrude tongue out
• No fasciculation
• No wasting of muscles
 MOTOR EXAMINATION
• BULK
On inspection there is no wasting of muscles on the
right upper and lower limb
• UPPER LIMB:
RIGHT LEFT
MID ARM 21 CM 21 CM
MID FOREARM 19cm 19 CM
• LOWER LIMB:

RIGHT LEFT
MID THIGH 33.5 CM 33.5 CM
MID CALF 30 CM 30 CM
• TONE:
RIGHT LEFT

UPPER LIMB Increased (spastic) Normal

LOWER LIMB Increased (spastic) Normal

• POWER:

UPPER LIMB RIGHT LEFT

SHOULDER
FLEXION 2/5 5/5
EXTENSION 2/5 5/5
ABDUCTION 2/5 5/5
ADDUCTION 2/5 5/5

ELBOW
FLEXION 2/5 5/5
EXTENSION 2/5 5/5
WRIST Right Left

FLEXION 2/5 5/5

EXTENSION 2/5 5/5

PRONATION 2/5 5/5

SUPINATION 2/5 5/5

ABDUCTION 2/5 5/5

ADDUCTION 2/5 5/5

FINGERS RIGHT LEFT
FLEXION 2/5 5/5
EXTENSION 2/5 5/5

THUMB RIGHT LEFT

FLEXION 2/5 5/5

EXTENSION 2/5 5/5

ABDUCTION 2/5 5/5

ADDUCTION 2/5 5/5

OPPOSITION 2/5 5/5

HIP JOINT RIGHT LEFT
FLEXION 3/5 5/5
EXTENSION 3/5 5/5
ABDUCTION 3/5 5/5
ADDUCTION 3/5 5/5
KNEE JOINT
FLEXION 3/5 5/5
EXTENSION 3/5 5/5
ANKLE JOINT
DORSIFLEXION 3/5 5/5
PLANTARFLEXION 3/5 5/5
INVERSION 3/5 5/5
EVERSION 3/5 5/5
TOES
FLEXION 3/5 5/5
EXTENSION 3/5 5/5
 REFLEXES
SUPERFICIAL REFLEX RIGHT LEFT
CORNEAL + +
CONJUNCTIVAL + +
PHARYNGEAL + +
ABDOMINAL + +
CREMASTIC + +
PLANTAR Babinski positive Normal
DEEP REFLEX
BICEPS Exaggerated Normal
TRICEPS Exaggerated Normal
SUPINATOR Exaggerated Normal
KNEE Exaggerated Normal
ANKLE Exaggerated Normal
 COORDINATION
RIGHT LEFT
Finger nose test Not able to perform Able to perform
Finger Finger nose test Not able to perform Able to perform
Tapping in a circle Not able to perform Able to perform
Dysdiadochokinesis Not able to perform Able to perform
Heel knee test Not able to perform Able to perform
Foot pat test Not able to perform Able to perform

GAIT-
Patient can walk with support
CIRCUMDUCTION GAIT is seen on the right side
 SENSORY SYSTEM
SUPERFICIAL SENSATION RIGHT LEFT
TOUCH Normal Normal
PAIN Normal Normal
DEEP SENSATION
PRESSURE Normal Normal
DEEP PAIN Normal Normal
VIBRATION SENSE Normal Normal
POSITION SENSE Normal Normal
CORTICAL SENSATION
TACTILE LOCALIZATION Normal Normal
TWO POINT Normal Normal
DISCRIMINATION
STEREOGNOSIS Normal Normal
GRAPHASTHESIA Normal Normal
 Other system
• Examination of CVS : S1, S2 heard, No murmurs heard
• Examination of RS : normal vesicular breath sounds
heard , No added sounds
• Examination of GIT : soft, non tender, no
organomegaly
• Examination of spine and cranium: No deformities.
 DIAGNOSIS
• A case of CVA wth right sided hemiparesis with
equal involvement of both upper and lower limbs
associated with ipsilateral UMN type of fascial
palsy with probable site of lesion at the left
internal capsule which is supplied by the
lenticulostriate branches of M1 segment of the
left middle cerebral artery probably due to
thrombosis of the vessel
 INVESTIGATION
• CT scan
• Complete blood count (TLC, DLC, RBC, Hb, RBC indices, PS, ESR,
CRP)
• Blood sugar (fasting, PP, Random)
• lipid profile ( total cholesterol, LDL, HDL, LDL:HDL, Triglycerides)
• Angiography
• ECG
• Echocardiography , 3D Colour doppler
• MRI
• Magnetic resonance arteriogram
• Magnetic resonance venogram
• Coagulation profile:
– Serum fibrinogen
– Platelet count
– Bleeding time
– Clotting time
– PT, APTT
• Electrolyte status: (Na+,K+ ,Ca2+, Mg+)
• Liver function test : (serum bilirubin, serum albumin, serum
globulin, A:G ratio
• Renal function test : blood urea, serum creatinine, creatinine
clearance rate, albumin creatinine ratio, Urine protein
 TREATMENT
• GENERAL SUPPORTIVE MEASURES
• Nutrition and diet
• Smoking cessation
• BP management- (alpha + beta blocker ) labetalol- 10
mg/kg/day
. Calcium channel blocker- amlodipine ,Nifidipine
Vasodialator(Nitroprusside) 0.2-0.8mg/kg
. If hypotension- 0.9% NS 3.5 mg / kg over 24 hrs
• Specific
• Antiplatelet drugs-aspirin 75mg/day long term prophylaxis
• Anticoagulants –heparin and warfarin
• Thrombolytics –Alteplase(t-PA)
• Surgery-mechanical thrombectomy with recanulization
• Physiotherapy-as soon as until functioning of limbs
• Rehabilitation -speech therapy