LONG CASE : A 50 YEAR OLD WOMAN WITH LEFT-SIDED WEAKNESS AND DEVIATION OF MOUTH TO THE RIGHT

 HALL TICKET NUMBER : 1601006103

A 50-year-old housewife, from Suryapet, came to the hospital with the

Chief Complaints :

1) Weakness in the left upper and lower limbs

2) Slurred speech

3) Deviation of mouth to the right

 since 2 days

History of Presenting illness : 

The patient was apparently asymptomatic 2 days ago, when at around 9 AM in the morning, on 20th April :

• 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 and equal inability to move the left part of her body, following which she was brought to the hospital, at around 3 PM.
• At the onset of the attack, patient complained of dizziness followed by a fall.
• The patient's attendant observed that the patient had deviation of mouth to the right side and that her speech was slurred, 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 Diplopia 

Past history : 

• She is a known case of Hypertension since 9 years and Type 2 Diabetes Mellitus since 8 years,  for which she is regularly taking medication.
• No history of CVA, CAD, Tuberculosis and Epilepsy.

Family history : 

• There is no history of similar complaints in the family.

Personal history : 

• She consumes mixed diet.
• Normal appetite. 
• Sleep adequate. 
• Regular bowel and bladder movements. 
• History of alcohol consumption of 60 ml per day for 15 years now.

Treatment history : 

• Tab. Telmisartan 40mg OD 
• Tab. Glimepiride 0.2mg, Metformin 500 mg BD

General Examination : 

• 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.
• There is no Pallor, Icterus, Clubbing, Cyanosis, Generalized lymphadenopathy and Edema.
• Vitals :
• Temperature = 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
• Respiratory rate = 16 cycles per minute.

Systemic examination :

Central nervous system examination :-

1) Higher mental functions :

• Patient is conscious, oriented to time, place and person
• Memory - Immediate , recent and remote memory is intact
• Speech is slurred
• Right handedness

2) Motor system examination :

a) Bulk                 Rt.          Lt.

                         Normal    Normal

b)Muscle tone    Rt.          Lt.

   Upper limb   Normal   Hypotonia 

   Lower limb   Normal    Hypotonia

c) Muscle power   Rt.       Lt.

   Upper limb         5/5      0/5

   Lower limb         5/5      0/5 

d) Reflexes          Rt.        Lt.

    Superficial       

     Corneal            +         +

     Conjunctival    +         +

     Abdominal      +          +

     Plantar        Flexor     Extensor

 Deep tendon     Rt.            Lt.

   Biceps             2+            3+

   Triceps            2+            3+

   Supinator        2+            2+

   Knee                2+            3+

   Ankle               1+            2+

4) Sensory system examination :

                            Rt.                Lt

• Pain.                  +                   +

• Crude touch     +                   +

• Fine touch        +                   +

• Proprioception   normal        normal

• Stereognosis     normal        normal

• Two point discrimination normal   normal 

5) Cranial Nerve Examination :

• Olfactory- can perceive the smell on both sides

• Optic- visual acuity - 6/6,Visual field, colour vision, reflexes - normal 

• 3, 4, 6 cranial nerves - ocular movements - normal

                                  - No ptosis or nystagmus

                                  - Normal and reactive pupils

• Trigeminal - Motor and sensory functions normal on both sides

• Facial - 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.

• Vestibulocochlear nerve- Rinne's test - AC> BC; Weber's is centralised , schwabach test normal on both sides

• Vagus and glossopharyngeal - Gag reflex present , uvula in midline

• Spinal accessory - Trapezius and sternocleidomastoid are normal 

• Hypoglossal nerve - No deviation of tongue; normal movements

Other Systems examination :-

• 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 :

• Left-sided Hemiplegia with Left UMN Facial Palsy
• Due to Lesion in The Right Internal Capsule involving the lenticulostriate branch of the MCA
• Vascular in etiology - Thrombotic Stroke
• Due to Hypertension/ Diabetes mellitus

Treatment :

• 20 % MANNITOL I.V. - 20 gm
• TAB. ECOSPIRIN 150 mg OD
• TAB. ATORVASTATIN 40 mg OD
• TAB. CLOPIDOGREL 75 mg OD
• TAB. TRAMADOL BD
• Physiotherapy of left upper limb and lower limb

Deviation of angle of mouth towards right

Video showing Extensor plantar reflex

CT Scan of the Brain : showing a Hypodense lesion - likely an infarct

ECG showing Left Axis Deviation