HALL TICKET NO : 1601006004 - LONG CASE
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HISTORY OF PRESENT ILLNESS : The patient was apparently asymptomatic 3days ago, then she had dizziness.
Then she developed weakness in her left upper and lower limbs followed by fall. Weakness was sudden in onset and rapidly progressed to a state where she was unable to move her left side of the body.
It was associated with drooping of angle of mouth on left side with speech difficulty and there was deviation of mouth to right side associated with drooling of saliva.
No history of loss of consciousness, memory loss, seizure activity, behavioural abnormalities, bowel or bladder incontinence or visual disturbances.
No history of fever, nausea, vomiting, headache, chest pain and dyspnea.
PAST HISTORY :
- No similar complaints in the past.
- She is a known case of hypertension and diabetes since 4yrs which is under control by medication.
- No history of epilepsy, TB, asthma, cardiovascular diseases, thyroid diseases.
FAMILY HISTORY : Not significant.
MENSTRUAL HISTORY :
She underwent hysterectomy 4yrs back for fibroid uterus.
PERSONAL HISTORY :
. Diet - mixed
. Appetite - normal
. Sleep - adequate
. Bowel and bladder movements - regular.
. No addictions
ALLERGIC HISTORY :
No known allergic history.
GENERAL EXAMINATION :
Patient is conscious, coherent and cooperative.
Well oriented to time, place and person.
Moderately built and nourished.
No pallor, icterus, cyanosis, koilonychia, lymphadenopathy and edema.
Vitals -
. Temperature - afebrile
. Pulse - 75bpm
. RR - 17cpm
. BP - 110/80mm Hg
SYSTEMIC EXAMINATION :
NERVOUS SYSTEM -
1. HIGHER MENTAL FUNCTIONS -
. No loss of consciousness
. No loss of memory
. No behaviour abnormality
2. CRANIAL NERVES -
. Olfactory nerve - intact on both sides
. Optic nerve - intact on both sides
. Oculomotor nerve - intact on both sides
. Trochlear nerve - intact on both sides
. Trigeminal nerve - intact on both sides
. Abducens nerve - intact on both sides
. Facial nerve -
- Nerve affected on left side
- Deviation of mouth to right
- Frowning present
- Absent nasolabial fold on left side
- Blowing and whistling absent
. Vestibulocochlear nerve - intact
. Glossopharyngeal nerve - intact
. Vagus nerve - intact
. Hypoglossal nerve - intact
. Spinal accessory nerve - intact
3. MOTOR SYSTEM -
a) Tone : Right Left
Upper limbs Normal Hypotonia
Lower limbs Normal Hypotonia
b) Power :
Upper limbs 5/5 0/5
Lower limbs 5/5 4/5
c) Reflexes :
i) Superficial Reflexes
. Corneal reflex present present
. Conjunctival reflex present present
. Plantar reflex flexor extensor
ii) Deep Reflexes
. Biceps +2 +3
. Triceps +2 +2
. Knee +2 +3
. Ankle not elicited not elicited
4. SENSORY SYSTEM -
. Superficial - fine touch, temperature, pain present
. Deep - position, vibration, 2point discrimination, stereognosis, graphasthesia present.
5. CEREBELLAR FUNCTIONS - normal
6. COORDINATION AND GAIT -
Coordination - finger nose test, heel knee test present.
Gait - dragging type.
Romberg's negative.
7. SIGNS OF MENINGEAL IRRITATION - Absent.
OTHER SYSTEMS :
CVS - S1, S2 heard
RESPIRATORY - Bilateral Air entry present
PER ABDOMEN - normal (bowel sounds heard)
INVESTIGATIONS :
CT SCAN - normal
ECG :
PROVISIONAL DIAGNOSIS :
Left UMN Facial palsy with left sided HEMIPARESIS.
