Case history 2
45 years old, female
Pandikadu
Agriculture worker,
History from husband
Presenting complaints
1. Deviation of angle of mouth to left
2. Weakness of right upper and lower limbs

12 days
History of present illness
Abrupt onset deviation of angle of mouth to left
side and weakness of both right upper and
lowe...
• Attended a funeral function and was stressed
after that, complained of sudden onset
giddiness
• 2-3 hours later relative...
On the way, there was abnormal jerky
movement of all limbs, lasted for few minutes.
It was associated with frothy discharg...
Was admitted in ICU, bladder catheterised,
nasogastric tube inserted.
Shifted to ward 3 days back, was drowsy,
not oriente...
Not able to open her right eye
History of faecal incontinence
No h/o fever, headache, projectile vomiting,
neck stiffness
...
History of past illness
Had history of fever and joint pain 22 years
back.
• 6 months later she had gradual onset
dyspnoea...
• Detected to have valvular heart disease,
advised surgery,13 yrs back
• On regular medication (Kaypen, Betaloc,
Amifru) d...
• h/o orthopnea and paroxysmal nocturnal
dyspnoea for past 4-5 months
• h/o recurrent fever, sore throat
• h/o hypertensio...
Family history
DM, HT, CVA

CHD

•Father hypertensive and
diabetic,
h/o stroke 2 years back
•Her mother died when she was
...
Personal history
• Takes mixed diet
• Sleep and appetite normal prior to onset of
symptoms
• Bladder incontinence present ...
Socioeconomic history
• Living with her family in 3 bed room concrete
house, husband is an agricultural worker,
proper wat...
General examination
•
•
•
•
•

Lying supine on bed
Drowsy, responds to painful stimuli & localises it
Moderately build and...
• Nasogastric tube in situ
• Bladder catheterised, clear urine
• IV cannula present on both hands.
Vital signs
• Pulse rate: 103/min
• Irregularly irregular, with apex pulse deficit
13/min
• Variable volume
• Character an...
• Blood pressure: 110/70 mm Hg, right arm
supine position
• Respiratory rate: 42/min, regular,
thoracoabdominal
• She is a...
System examination
Nervous system
Patient lying supine on bed with right
shoulder adducted, with extended
elbow, forearm p...
• Right lower limb extended, adducted and
externally rotated at hip, knee extended, foot
plantiflexed
• Left lower limb ab...
Higher mental function
• She is drowsy
• Eye opening 3
GCS 9
Verbal response 1
Motor response 5
• Not oriented to place, p...
Cranial nerve examination
• Olfactory nerve not assessed
• Optic nerve: fundus not examined
• Occulomotor, trochlear, abdu...
• Trigeminal nerve: corneal and conjunctival
reflex not assessed
• Facial nerve: Angle of mouth deviated to left
Nasolabia...
Motor system
Bulk
Right (cm)

Left (cm)

Arm

22

22

Forearm

20

20

Thigh

39

39

Calf

26

26

Upper limb

Lower limb...
• Power
• Right: Upper limb not moving (grade 0)
Lower limb not moving (grade 0)
• Left: Upper limb moving spontaneous aga...
Reflexes
Superficial reflexes

right

left

corneal

Not done

Not done

conjunctival

Not done

Not done

Superficial abd...
• Primitive reflexes absent
• Sensory system and coordination cannot be
assessed
• No peripheral nerve thickening
• Skull ...
Cardiovascular system
•
•
•
•
•
•
•

Inspection
Prominent venous pulsations
Trachea central
Chest wall symmetrical
No prec...
•
•
•
•

Palpation
JVP not measured
Trachea central
Apex beat palpable at left sixth intercostal space
on midclavicular li...
•
•
•
•
•

Percussion
Right cardiac border behind sternum
Left cardiac border corresponds to apex
2nd left intercostal spa...
Auscultation
•
•
•
•

Mitral area: Loud 1st heart sound,
2nd heart sound heard with normal split
No 3rd and 4th heart soun...
• Tricuspid area
• Aortic area

1st heart sound normal
2nd heart sound heard
with normal split
No 3rd and 4th heart
sounds...
Respiratory system
• Trachea central, respiratory movements equal
on both sides
• Normal vesicular breath sound normal
int...
Gastrointestinal system
• Shape of abdomen normal
• Liver not palpable
• Normal bowel sounds heard
Summary
• 45years old, lady, with past h/o rheumatic fever
22 years back,
• gradually progressive dyspnea, palpitation 6
m...
• With drug default 20 days back presented
with giddiness followed by loss of
consciousness,
• Abrupt onset deviation of a...
• On examination pallor present,
clubbing grade I present,
• pulse rate 103/min, irregularly irregular, apex
pulse deficit...
•
•
•
•
•
•

On nervous system examination,
She is drowsy GCS 9,
Nasolabial fold absent on right,
Angle of mouth deviated ...
• On cardiovascular examination apex beat felt
at left sixth intercostal space on midclavicular
line,
• left parasternal i...
Diagnosis
• Cerebrovascular accident, right sided hemiplegia
with right upper motor neuron facial
palsy, embolic in origin...
Investigations
•
•
•
•
•
•
•
•

Hb 15 g/dl
TC 19800
DC N88 L11.5
ESR 73
Platelet 1.76 lakhs
MCV, PCV 84.2/45.8
MCHC 33.9
R...
•
•
•
•

Urine routine
Albumin +
Sugar
nil
Microscopy RBC 15
PC 2-3
epi 3-5
• LFT TB/DB 4.4/0.7
•
Albumin 7.4/3.7
•
SGOT/SGPT -/19
•
ALP 71
•
PT INR 21.9/1.65
•
RBS 352
Chest X-RAY

Chest X ray
C
T
B
R
A
I
N
Treatment
•
•
•
•
•
•
•
•
•

Inj Manitol 100ml iv Q8H
Inj Taxim 1 g IV Q8H
Inj metrogyl 500 mg iv Q8H
IVF 1 . NS slow
Inj ...
Case history 2
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case study hemiplegia

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  • She was detected to have cardiac disease, which she often complains gradually progressive dyspnoea and palpitation, and is on regular medication for past 18 years.
  • Pain was associated with swelling and redness of ankle, knee, elbow joints, migratory type of pain. Injection given for 1 week, took ayurvedic treatment for 1 month, symptoms relieved by 1 month and there was no deformities of joints involved
  • First child born out of non consanguineous marriage
  • Case history 2

    1. 1. Case history 2
    2. 2. 45 years old, female Pandikadu Agriculture worker, History from husband
    3. 3. Presenting complaints 1. Deviation of angle of mouth to left 2. Weakness of right upper and lower limbs 12 days
    4. 4. History of present illness Abrupt onset deviation of angle of mouth to left side and weakness of both right upper and lower limb for last 12 days
    5. 5. • Attended a funeral function and was stressed after that, complained of sudden onset giddiness • 2-3 hours later relatives found her lying floppy on the bed, was unconscious, not responding to call, not moving any limb with deviation of angle of mouth towards left.
    6. 6. On the way, there was abnormal jerky movement of all limbs, lasted for few minutes. It was associated with frothy discharge from mouth, involuntary passage of urine. No h/o tongue biting.
    7. 7. Was admitted in ICU, bladder catheterised, nasogastric tube inserted. Shifted to ward 3 days back, was drowsy, not oriented to place or person, unable to move right upper and lower limb, but opens her left eye when called, speech output was nil except for some grunting sound she produce.
    8. 8. Not able to open her right eye History of faecal incontinence No h/o fever, headache, projectile vomiting, neck stiffness No h/o (nasal regurgitation)
    9. 9. History of past illness Had history of fever and joint pain 22 years back. • 6 months later she had gradual onset dyspnoea( NYHA II) • Fever, respiratory infections aggravated the symptoms. Within 2 years symptoms worsened (NYHA III) • Associated with palpitation, irregular, rest
    10. 10. • Detected to have valvular heart disease, advised surgery,13 yrs back • On regular medication (Kaypen, Betaloc, Amifru) daily, also advised to reduce emotional stress and severe exertion. • (She was unable to continue medication for 20 days before admission)
    11. 11. • h/o orthopnea and paroxysmal nocturnal dyspnoea for past 4-5 months • h/o recurrent fever, sore throat • h/o hypertension for past 20 years, on medication • No h/o diabetes, treatment for pulmonary tuberculosis, epilepsy • No h/o similar weakness
    12. 12. Family history DM, HT, CVA CHD •Father hypertensive and diabetic, h/o stroke 2 years back •Her mother died when she was 2 years old, cause unknown. •Father married again,2 children, younger child had valvular heart disease at 3 yrs, surgery done, now asymptomatic , now she is 15 yrs •She married at the age of 12, 3 children, PPS done 22 years back
    13. 13. Personal history • Takes mixed diet • Sleep and appetite normal prior to onset of symptoms • Bladder incontinence present and catheterised • Bowel incontinence present one episode • No addictions
    14. 14. Socioeconomic history • Living with her family in 3 bed room concrete house, husband is an agricultural worker, proper water and sanitation facilities. Belongs to a middle class family.
    15. 15. General examination • • • • • Lying supine on bed Drowsy, responds to painful stimuli & localises it Moderately build and nourished Pallor and clubbing (grade I) present No icterus, cyanosis, lymphadenopathy, pedal oedema
    16. 16. • Nasogastric tube in situ • Bladder catheterised, clear urine • IV cannula present on both hands.
    17. 17. Vital signs • Pulse rate: 103/min • Irregularly irregular, with apex pulse deficit 13/min • Variable volume • Character and condition of vessel wall normal • No radio radial or radio femoral delay • All peripheral pulses palpable bilaterally equal
    18. 18. • Blood pressure: 110/70 mm Hg, right arm supine position • Respiratory rate: 42/min, regular, thoracoabdominal • She is afebrile
    19. 19. System examination Nervous system Patient lying supine on bed with right shoulder adducted, with extended elbow, forearm pronated, fingers slightly flexed Left shoulder slightly abducted, forearm flexed at elbow, fingers slightly flexed
    20. 20. • Right lower limb extended, adducted and externally rotated at hip, knee extended, foot plantiflexed • Left lower limb abducted and flexed at hip, flexed at knee, foot in neutral position • Gaze preference to left side
    21. 21. Higher mental function • She is drowsy • Eye opening 3 GCS 9 Verbal response 1 Motor response 5 • Not oriented to place, person and time • Speech output nil, make abnormal grunts • Memory, intelligence cannot be assessed • Right handed person • Mother tongue malayalam
    22. 22. Cranial nerve examination • Olfactory nerve not assessed • Optic nerve: fundus not examined • Occulomotor, trochlear, abduscent nerve: right left Ptosis present normal Size and shape of pupil 3-4 cm, round, regular 3-4 cm, round, regular Direct light reflex present present indirect reflex present present
    23. 23. • Trigeminal nerve: corneal and conjunctival reflex not assessed • Facial nerve: Angle of mouth deviated to left Nasolabial fold absent on right Grimace absent on right • Vestibulocochlear nerve: normal dolls eye reflex
    24. 24. Motor system Bulk Right (cm) Left (cm) Arm 22 22 Forearm 20 20 Thigh 39 39 Calf 26 26 Upper limb Lower limb Tone right left Upper limb Hypotonic Normal tone Lower limb Hypotonic Normal tone
    25. 25. • Power • Right: Upper limb not moving (grade 0) Lower limb not moving (grade 0) • Left: Upper limb moving spontaneous against gravity Lower limb moving spontaneous against gravity
    26. 26. Reflexes Superficial reflexes right left corneal Not done Not done conjunctival Not done Not done Superficial abdominal absent present Plantar response No response flexor Deep tendon reflexes right Jaw jerk left absent Supinator jerk brisk present Biceps jerk brisk present Triceps jerk brisk present Knee jerk brisk present Ankle jerk brisk present clonus absent absent
    27. 27. • Primitive reflexes absent • Sensory system and coordination cannot be assessed • No peripheral nerve thickening • Skull and spine normal • No carotid bruit
    28. 28. Cardiovascular system • • • • • • • Inspection Prominent venous pulsations Trachea central Chest wall symmetrical No precordial bulge Apical impulse not visible No visible pulsations, scar, dilated vein
    29. 29. • • • • Palpation JVP not measured Trachea central Apex beat palpable at left sixth intercostal space on midclavicular line, tapping in character • Left parasternal impulse felt, no heave • No thrill • Palpable epigastric pulsation present
    30. 30. • • • • • Percussion Right cardiac border behind sternum Left cardiac border corresponds to apex 2nd left intercostal space resonant Liver dullness present in right fifth intercostal space in mid clavicular line
    31. 31. Auscultation • • • • Mitral area: Loud 1st heart sound, 2nd heart sound heard with normal split No 3rd and 4th heart sound A low pitched diastolic rumbling murmur of grade III is audible at apex, without any radiation, with bell of stethoscope with patient lying in left lateral position, at the height of expiration, opening snap present.
    32. 32. • Tricuspid area • Aortic area 1st heart sound normal 2nd heart sound heard with normal split No 3rd and 4th heart sounds No murmur • Pulmonary area: 1st heart sound normal 2nd heart sound loud No 3rd and 4th heart sounds No murmur
    33. 33. Respiratory system • Trachea central, respiratory movements equal on both sides • Normal vesicular breath sound normal intensity in all chest areas, bilateral basal crepitations present
    34. 34. Gastrointestinal system • Shape of abdomen normal • Liver not palpable • Normal bowel sounds heard
    35. 35. Summary • 45years old, lady, with past h/o rheumatic fever 22 years back, • gradually progressive dyspnea, palpitation 6 months later, • detected to have cardiac disease 18 years back on regular medication, • hypertensive for past 18 years, • orthopnea and paroxysmal nocturnal dyspnea for past 4 months,
    36. 36. • With drug default 20 days back presented with giddiness followed by loss of consciousness, • Abrupt onset deviation of angle of mouth to left and weakness of right upper and lower limb for past 12 days, • No speech output, • Bladder and bowel incontinence present
    37. 37. • On examination pallor present, clubbing grade I present, • pulse rate 103/min, irregularly irregular, apex pulse deficit 13/min, variable volume, tachypnea present
    38. 38. • • • • • • On nervous system examination, She is drowsy GCS 9, Nasolabial fold absent on right, Angle of mouth deviated to left, Right sided ptosis present, Hypotonic, brisk deep tendon reflexes and plantar response mute on right side
    39. 39. • On cardiovascular examination apex beat felt at left sixth intercostal space on midclavicular line, • left parasternal impulse present, • epigastric pulsation present, • on auscultation loud 1st heart sound heard, low pitched diastolic murmur heard in mitral area, loud 2nd heart sound in pulmonary area.
    40. 40. Diagnosis • Cerebrovascular accident, right sided hemiplegia with right upper motor neuron facial palsy, embolic in origin, involving left middle cerebral artery, recovery from neuronal shock, • Etiology being acquired valvular heart disease, mitral stenosis, rheumatic in etiology, with atrial fibrillation, systemic hypertension. • No features of congestive cardiac failure, infective endocarditis, pulmonary hypertension
    41. 41. Investigations • • • • • • • • Hb 15 g/dl TC 19800 DC N88 L11.5 ESR 73 Platelet 1.76 lakhs MCV, PCV 84.2/45.8 MCHC 33.9 RDW 12.4
    42. 42. • • • • Urine routine Albumin + Sugar nil Microscopy RBC 15 PC 2-3 epi 3-5
    43. 43. • LFT TB/DB 4.4/0.7 • Albumin 7.4/3.7 • SGOT/SGPT -/19 • ALP 71 • PT INR 21.9/1.65 • RBS 352
    44. 44. Chest X-RAY Chest X ray
    45. 45. C T B R A I N
    46. 46. Treatment • • • • • • • • • Inj Manitol 100ml iv Q8H Inj Taxim 1 g IV Q8H Inj metrogyl 500 mg iv Q8H IVF 1 . NS slow Inj pantoprazole 40 mg iv od Inj Lasix 40mg IV Q8H T Atorvastatin 10 mg HS T. Carvedilol 3.125 mg ½-0-1/2 t. Digoxin 0.25mcg 1-0-0

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