Sajir, a 7-year-old boy, presented with a one-week history of headache and weakness in his left side. He developed mouth deviation two days prior. On examination, he had upper motor neuron facial palsy on the right side and brisk reflexes in his left upper and lower limbs. A CT scan found an acute infarct in the right middle cerebral artery territory of his brain. The provisional diagnosis was acute stroke syndrome, and differential diagnoses included ADEM and ICSOL.

1. Welcome to clinical meeting
Dr Ekramul Haque
MD Phase-A

2. Particulars of the patient
 Name : Sajir
 Age : 7 years
 Sex : Male
 Father’s name : Sayed babul
 Mother’s name : jinnat
 Address : Hathazari, Chattogram.
 Ward no. : 9
 Date of admission : 20.10.2023
 Date of examination : 24.10.2023

3. Presenting Complaints
• Headache for 7 days.
• Weakness & tingling sensation in left upper & lower limb for 7
days
• Deviation of mouth for 2 days

4. History of Present Illness
According to the statement of informant mother, her
child was reasonably well about 7 days back. Then her
child complain of headache which was localized in
forhead region,mild in intensity. Then She noticed her
child was facing difficulties during walking,due to
weakness & tingling sensation in left upper & lower
limb.but no tendency to fall during walking,Baby was
also unable to hold anything properly by his left hand.
She also noticed that, Deviation of mouth of her son
when was speaking,eating anything for last 2 days.

5. Continued…
There is no history of any injury or fall from height, fever, rash,
convulsion, loss of consciousness, bladder & bowel incontinence,
jaundice, difficulties in swallowing, irritable cry, and any visual
problems. There is also no history of cough and contact with any
TB patient, bluish discoloration of lips & tongue, breathing
difficulties.
With above complaints, patient was visited to a qualified
physician by his parents and the physician has referred him to
the Department of Pediatrics, CMCH for further evaluation and
better management.

6. History of past illness
History of febrile convulsion for 2 times.

7. Birth History
Patient was delivered by C/S at clinic,due to large head of baby.
His mother was on antenatal check up during pregnancy.
Pregnancy period was uneventful. Natal and post natal history
was also uneventful.

8. Feeding history
Patient was on EBF up to 6 months. Then complementary feeding
was initiated along with breast-feeding and breast-feeding was
continued up to 2 years. Now patient was on family diet.

9. Immunization History
Patient is immunized as per EPI schedule.
Developmental history
Developmental milestones were age
appropriate.

10. Socio-economic History
Patient belongs to poor socio-economic family.
Family History
3rd issue of non consanguineous parents.1st child was dead due to
VLBW at birth. Other family meebers are in good health, and no
history of such type of illness among the family members and
relatives.

11. General Examination
 Appearance : Ill looking.
 Decubitus : Lying posture
 Pallor : absent
 Icterus : Absent
 Skin survey : BCG scar present
 Clubbing :
 Oedema :
 Dehydration :
 Koilonychia :
 Leuconychia :
Absen
t
Vital signs
 Heart rate : 90/min
 BP : 90/60
mmHg(50 th percentile)
 Temperature : Normal
 Resp. rate : 24/min

12. • BMI=[weight(kg)/Height(m)^2]
• 15.05 kg/m^2(25- 50 th percentile).
• MPH-Familial short stature

13. Examination of Nervous System
 Higher function : Patient is conscious, cooperative
GCS-E4M6V5(15/15)
 Cranial nerves:
So far examined, eyes are normal, UMNL of facial nerve palsy(rt)
present
 Motor system:
 Muscle bulk - Normal
 Muscle tone - Normal
 Muscle power -5/5 in right lower limbs, 4/5 in left lower limbs.
 Jerks – Knee and ankle jerks brisk in left lower limb.
Plantar reflex – flexor in right side, equivocal in left side.

14.  Motor system of upper limb:
Tone is Normal
Power: 5/5 in right, 4/5 in left
Jerks: Biceps, triceps jerks are brisk in left side.
 Sensory system: intact
 Cerebellar Function: intact.
 Gait: intact.
 Back & spine: Normal.

15. Other systemic examination reveals nothing abnormalities.

16. Salient Feature
Sajir, 7 years old boy hailing from hathazari, Chattogram,3rd issue
of non consanguineous parents has been admitted in CMCH on
20,October 2023 with the complaints of Headache in forhead for 7
days,difficulties in walking & weakness in left side of body for 7
days, Deviation of mouth for last 2 days when opening of mouth
during eating. No history of trauma, fever, rash, convulsion, loss
of consciousness, bladder & bowel incontinence, jaundice,
difficulties in swallowing, and any visual problems. There is also
no history of cough and contact with any TB patient.

17. On examination, patient was found ill-looking, conscious,
cooperative, anicteric, having normal vital signs. Skin survey
revealed presence of BCG mark, having no lymphadenopathy, no
signs of meningeal irritations and normal back and spines. BMI is
15.05 kg/m^2(25-50 th percentile,MPH reveals Familial short
stature. Neurological examination reveals UMNL of facial
palsy(rt) is present. lt knee, ankle, biceps & triceps jerks are
brisks in both upper & lower limb and equivocal plantar reflex of
lt lower limb. There is no abnormal eye gaze or squint. Others
cranial nerve functions, sensory system, gait, cerebellar signs
remians intact. Other systemic examinations revealed no
abnormalities.

18. Provisional Diagnosis
Acute Stroke Syndrome with familial short stature.
Differential Diagnoses
ADEM
ICSOL

19. Investigations
CT Scan of Brain:
There is an indistinct hypo-attenuated area in rt fronto-parieto-
temporal lobe which demontrates
Rt MCA territory Acute Infarct.
Gold Standard: MRI of Brain with MRA