case study hemiplegia

1. Case history 2

2. 45 years old, female
Pandikadu
Agriculture worker,
History from husband

3. Presenting complaints
1. Deviation of angle of mouth to left
2. Weakness of right upper and lower limbs
12 days

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. • 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. 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. 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. 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. 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. • 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. • 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. 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. 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. 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. 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. • Nasogastric tube in situ
• Bladder catheterised, clear urine
• IV cannula present on both hands.

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. • Blood pressure: 110/70 mm Hg, right arm
supine position
• Respiratory rate: 42/min, regular,
thoracoabdominal
• She is afebrile

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. • 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. 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. 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. • 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. 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. • 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. 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. • Primitive reflexes absent
• Sensory system and coordination cannot be
assessed
• No peripheral nerve thickening
• Skull and spine normal
• No carotid bruit

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. •
•
•
•
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. •
•
•
•
•
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. 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. • 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. 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. Gastrointestinal system
• Shape of abdomen normal
• Liver not palpable
• Normal bowel sounds heard

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. • 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. • On examination pallor present,
clubbing grade I present,
• pulse rate 103/min, irregularly irregular, apex
pulse deficit 13/min, variable volume,
tachypnea present

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. • 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. 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. 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. •
•
•
•
Urine routine
Albumin +
Sugar
nil
Microscopy RBC 15
PC 2-3
epi 3-5

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. Chest X-RAY
Chest X ray

46. C
T
B
R
A
I
N

47. 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