LONG CASE : A 50-year-old lady with left-sided weakness of the body and deviation of the mouth towards the right

April 28, 2021

LONG CASE : A 50-year-old lady with left-sided weakness of the body and deviation of the mouth towards the right

HALL TICKET NUMBER : 1601006161

A 50-year-old lady, from Suryapet, who is a homemaker, came to the hospital on 20/04/2021 at 3 PM, and was examined on 24/04/2021 at 10 AM, with

Chief Complaints of :

1) Weakness of the left upper and lower limbs since 5 days

2) Deviation of the angle of mouth towards the right since 5 days

3) Slurred speech since 5 days

History of Presenting illness :

The patient was apparently asymptomatic 5 days ago, when at around 9 AM in the morning, on 20/04/2021 :

She felt a sudden weakness of her left upper and lower limbs.
The episode was sudden in onset, initially began as a slight weakness of the left upper limb, which progressively worsened with time and the evolution of weakness had completed within 6 hours, with a complete inability to move both - her left upper and lower limbs, following which she was brought to the hospital by her family members, at around 3 PM.
At the beginning of the attack, patient complained of dizziness followed by a fall on her hips.
The patient's attendant observed that the patient had deviation of mouth to the right side and that her speech was slurred . It was associated with drooling of saliva.
Not associated with convulsions, altered sensorium.
No history of headache, vomiting.
No history of loss of smell or alteration of smell.
No history of loss of vision, diplopia.
No difficulty in raising her eyebrows or closing her eyes.
No history of hearing loss.
No history of difficulty in swallowing.
No history of change in voice.
No history of chest pain, palpitations or prolonged fever.

Past medical history :

She is a known case of Hypertension since 9 years, for which she is regularly taking medication.
She is a known case of Type 2 Diabetes Mellitus since 8 years, for which she is regularly taking medication.
She denies any previous history of CVA, CAD, Tuberculosis and Epilepsy.

Past surgical history :

The patient underwent a Hysterectomy 9 years ago for fibroid uterus, during the hospital stay for the surgery, she was diagnosed with Hypertension and Diabetes mellitus.

Family history :

There is no history of similar complaints in the family.

Personal and social history :

She consumes a mixed diet.
Her appetite is normal.
She is sleeping adequately.
Her bowel and bladder movements are irregular as she feels constipated.
She has a history of consumption of 60 ml of alcohol per day, since 35 years of age. She denies any history of smoking.

Treatment history :

TAB. TELMISARTAN 40 mg , AMLODIPINE 12.5 mg OD
TAB. GLIMEPIRIDE 0.2 mg , VOGLIBOSE 0.2 mg , METFORMIN 500 mg BD
TAB. TENEGLIPTIN 20 mg OD

Allergy history :

The patient denies having any allergy to any drugs or foods.

Menstrual and Obstetric history :

Her last menstrual period (LMP) was on 11/04/2021
She attained menarche at 15 years of age
She regularly bleeds for 5 days every 28 days. She uses 2 pads per day. Her periods are not associated with cramping pain or clots.
At 15 years of age - Normal vaginal delivery of a male child - Alive
At 20 years of age - Normal vaginal delivery of a female child - Alive
At 25 years of age - Normal vaginal delivery of a male child - Alive

On General Physical Examination :

The patient is conscious, coherent and cooperative, lying supine on the bed.
She is well oriented to time, place and person.
She is well built and well nourished.
On head-to-toe examination, There is presence of :
Acanthosis nigricans on the nape of the neck.
Central adiposity.
There is no Pallor, Icterus, Clubbing, Cyanosis, Generalized lymphadenopathy and Edema.

Vitals :

Temperature = she is afebrile
Pulse = 82 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.
Blood pressure = 140/100 mm of Hg in the left arm in supine position.
Respiratory rate = 16 cycles per minute.

Neurological Examination :

On examination of the Higher Mental Functions :

- She is conscious and well oriented to date, time, season, year, place and person.

- Her speech is slurred.

- Her language is normal. Her short term and long term memory (when asked to repeat 3 names of objects and when asked what she had for dinner last night)

- She is able to perform basic calculations such as subtracting 7 from 100 five times (100, 93, 86, 79, 65)

- She is able to follow a 3-stage command.

- She is also able to read and obey a written command on a piece of paper ("Close your eyes")

On examination of the Motor System :

Right Left

1. Muscle Bulk Normal Normal

2. Muscle Tone

Upper limb

Shoulder Normal Hypotonia

Elbow Normal Hypotonia

Wrist Normal Hypotonia

Lower limb Normal Hypotonia

3. Muscle Power

Upper Limb

Proximal 5/5 0/5

Distal 5/5 0/5

Lower Limb

Proximal 4/5 0/5

Distal 5/5 0/5

4. Reflexes

Superficial reflexes

Right Left

Corneal + +

Conjunctival + +

Abdominal + +

Plantar Flexor Extensor

Deep tendon reflexes

Right Left

Biceps 2+ 3+

Triceps 2+ 3+

Supinator 2+ 2+

Knee 2+ 3+

Ankle 1+ 2+

On examination of the Cranial Nerves :

Cranial Nerve 1 : The patient can perceive the smell of soap
Cranial Nerve 2 : Counting fingers at 6 meters is normal
Cranial Nerves 3, 4 and 6 : Movements of the extra-ocular muscles, Pupillary reflex and Accommodation reflex are normal. There is no ptosis or nystagmus.
Cranial Nerve 5 : Sensory component = Ability to perceive sensation over specific areas on the face is Normal. Motor component = Jaw jerk was elicited and the muscles of mastication are normal.
Cranial Nerve 7 :
Upper half of the face (both right and left side) = spared : Symmetry of wrinkles on the forehead upon looking up is present. She is able to keep her eyes tightly shut against resistance

Lower half of the face (left side is affected) = There is deviation of the angle of the mouth towards the right, upon grinning. There is loss of nasolabial folds on the left side. She is unable to puff her cheeks.

Cranial Nerve 8 : Rinne's test = AC > BC , Weber's test is centralized.
Cranial Nerves 9 and 10 : Uvula is centrally placed and Gag reflex is present.
Cranial Nerve 11 : Trapezius and Sternocleidomastoid are normal.
Cranial Nerve 12 : Patient can normally move her tongue in all directions.

On examination of the Sensory System :

Right Left

1. Pain + +

2. Crude touch + +

3. Fine touch + +

4. Vibration sense

Medial malleolus 5.7s 4.6s

Patella 9s 4.3s

Elbow 4.8s 6.4s

Wrist 5s 7s

5. Proprioception Normal Normal

6. Stereognosis Normal Normal

7. Tactile localization Normal Normal

8. Two-point discrimination Normal Normal

Examination of other systems :

Cardiovascular system : S1, S2 is heard. No murmurs are heard.
Respiratory system : Bilateral air entry is present, Normal vesicular breath sounds are heard. No adventitious sounds are heard.
Per Abdomen : Soft, Non-tender

PROVISIONAL DIAGNOSIS :

FUNCTIONAL DIAGNOSIS :

Left hemiplegia with Left UMN Facial palsy

ANATOMICAL DIAGNOSIS :Mostly due to lesion in the Right Internal Capsule
Involving the Lenticulostriate branch of the Middle Cerebral Artery (MCA)
ETIOLOGICAL DIAGNOSIS :Mostly due to vascular etiology - Thrombotic in nature
Due to Hypertension/ Diabetes Mellitus
In the stage of neuronal shock
With no signs of raised ICT